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The Exorcist : childhood trauma and loss. Jon Frederickson, MSW. Multiple Sclerosis and Stress. Extensive research shows that stress triggers relapses in multiple sclerosis. Psychosomatic Medicine Nov-Dec 2002

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multiple sclerosis and stress
Multiple Sclerosis and Stress
  • Extensive research shows that stress triggers relapses in multiple sclerosis.
  • Psychosomatic Medicine Nov-Dec 2002
  • Mohr DC, Goodkin DE, Bacchetti P, et al. Psychological stress and the subsequent appearance of new brain MRI lesions in MS. Neurology 2000; 55:55-61
  • Mohr DC, Goodkin DE, Nelson S, et al. Moderating effects of coping on the relationship between stress and the development of new brain lesions in multiple sclerosis. Psychosom Med 2002; 64:803-809
  • Buljevac D, Hop WC, Reedeker W, et al. Self reported stressful life events and exacerbations in multiple sclerosis: prospective study. Bmj 2003; 327:646.
  • Feelings trigger anxiety.
  • Anxiety is discharged in the somatic, sympathetic, and parasympathetic nervous systems.
  • These systems prepare the body internally to response externally to a threat.
  • Muscles: to fight or flee.
  • Sympathetic nervous system: to support actions.
somatic nervous system striated muscles
Somatic Nervous System: Striated Muscles
  • Sighing
  • Clenching of the hands
  • Arms, neck and chest tense. Tension headaches.
  • Chest pains
  • Back pain and pain in the joints.
  • Tight stomach muscles
sympathetic nervous system
Sympathetic Nervous System
  • Dry mouth and eyes
  • Dilated pupils
  • Increased sweating, Cold hands and feet
  • Blushing
  • Increased heart rate, blood pressure, and respiration
  • Shivering
  • Gastrointestinal tract (decreased motility)
  • Piloerection muscles contract (hair stands on end)
  • Bladder (constrict sphincter---urinary retention)
parasympathetic nervous system smooth muscles and c p disruption
Parasympathetic Nervous System: Smooth Muscles and c/p disruption
  • Salivation, teary eyes
  • Constricted pupils
  • Warm hands
  • Migraine headaches
  • Decreased heart rate, blood pressure, and respiration
  • Gastrointestinal tract (increased motility)
  • Bladder (relaxed sphincter)---urge to urinate
  • Dizziness, foggy thinking
  • Bodily anaesthesia, limpness
parasympathetic nervous system ii
Parasympathetic Nervous System II
  • Localized weakness.. “Jelly legs”. Trouble walking.
  • Deafness, ringing in the ears, and roaring in the ears .
  • Blindness, blurry vision, and tunnel vision.
  • Fainting, loss of consciousness, or dizziness. Hypo-perfusion in the brain.
  • Amnesia and memory loss. Hippocampus shuts down.
  • Hallucinations.
  • No tension, but cognitively confused.
  • Sympathetic and parasympathetic nervous systems ideally are in balance.
  • When the parasympathetic nervous system cannot function properly, the immune system malfunctions resulting in an increase in Th1 cytokines (inflammation) and TNF production.
  • This imbalance is a factor in heart disease, auto-immune disorders, diabetes, and other chronic diseases. See Schulkin’s, Allostasis, Homeostasis, and the Costs of Physiological Adaptation.
what to do
What to Do?
  • Regulate the patient’s anxiety by improving the functioning of the parasympathetic nervous system.
  • This will reduce TNF production. Shock, April 2010 - Volume 33 (4): 363-368 Relationship of basal heart rate variability to in vivo responses after endotoxin exposure
  • And inhibit production of pro inflammatory cytokines. Psychosomatic Medicine October 2007. Stimulated Production of Proinflammatory Cytokines Covaries Inversely With Heart Rate Variability. Also see, Nature 420:853-9, 2002 .
  • Psychotherapy. NeurologyJuly 2012. Patients who attended six months of stress-management sessions had fewer brain lesions and a slower disease progression compared to people who didn't attend the sessions.
  • Their lesions were measured by magnetic resonance imaging. Two types of brain lesions in the study participants were observed — gadolinium-enhancing and T2. Patients with stress management therapy had fewer of each. "This is the first time counseling or psychotherapy has been shown to affect the development of new lesions."
  • Purpose today is to show how to help regulate anxiety in a patient with MS to improve anxiety regulation, immune function, and reduce the risk of MS relapses.
  • Stress, emotion activation, and anxiety occurs in all of us. Life.
  • Causation.
  • Find out the internal emotional problem for which the patient seeks our help.
  • Assess responses to intervention moment-to-moment to discern the triangle of conflict.
  • Assess anxiety discharge pattern and defenses to understand what causes the patient’s problems and symptoms.
anxiety assessment
Anxiety Assessment
  • Discern where anxiety is discharged in the body.
  • Striated muscles
  • Smooth muscles
  • Cognitive/perceptual disruption.
graded format
Graded Format
  • Explore feeling.
  • When anxiety goes out of striated muscles or the patient uses regressive defenses, pause.
  • Restructure the pathway of anxiety discharge or the regressive defenses.
  • Then explore feeling again.
  • Step by step build the patient’s capacity to bear feelings while anxiety is regulated.
cognitive recapitulation
Cognitive Recapitulation
  • To regulate anxiety, help the patient see the anxiety symptom and identify it as anxiety.
  • Point out causality.
  • Offer repressive defenses.
  • When anxiety returns to the striated muscles, explore feeling again.
conscious therapeutic alliance consensus on the triangle
Conscious Therapeutic Alliance: Consensus on the Triangle
  • To know what to do, the patient must know the task.
  • To know the therapeutic task, the patient must understand what the triangle of conflict is.
  • To learn the triangle of conflict, the patient must be shown moment-to-moment how it is active in session.
conscious therapeutic alliance mobilizing will to a positive goal
Conscious Therapeutic Alliance: Mobilizing Will to a Positive Goal
  • Positive vs. negative goals.
  • Aversion vs. approach
  • Clarifying the therapeutic task: why we do this.
  • Patient’s vs. therapist’s goals.
conscious therapeutic alliance consensus on the task
Conscious Therapeutic Alliance: Consensus on the Task
  • To let go of defenses which hurt the patient.
  • To face rather than avoid what makes the patient anxious.
  • To feel feelings as deeply as possible.
  • To overcome the patient’s difficulties and to achieve the patient’s positive goals.
  • Without consensus on task: no conscious therapeutic alliance.
pressure to feeling in the graded format building capacity
Pressure to Feeling in the Graded Format: Building Capacity
  • Invite feeling.
  • Restructure the pathway of anxiety discharge.
  • Restructure regressive defenses which create the patient’s presenting problems.
  • Excessive anxiety and regressive defenses are not “problems”: they indicate the next thing you need to heal. They are good information.
going over the threshold of anxiety tolerance
Going Over the Threshold of Anxiety Tolerance
  • When anxiety goes out of striated muscles into the smooth muscles or cognitive/perceptual disruption.
  • Pause.
  • Immediate anxiety regulation.
  • Failures: regression.
repressive defenses
Repressive Defenses
  • Intellectualization
  • Rationalization
  • Rumination
  • Denial
  • Forgetting
  • Negation
  • Slowing down
  • Isolation of affect
character defenses
Character Defenses
  • Based on identification.
  • I do to myself what others did to me.
  • I ignore my anxiety. “I’m always like this.”
  • I dismiss my anxiety. “It’s no big deal.”
  • I ridicule my anxiety. “It’s stupid.”
projection of the superego
Projection of the Superego
  • Triangle of conflict: Anger, anxiety, self-judgment.
  • I project: “You judge me.”
  • Spectrum of projection: anxiety, defenses, reality testing.
misuse of reality
Misuse of Reality
  • In the service of self punishment.
  • Do not dispute the reality or fact.
  • Point out the function it is being asked to serve: to punish.
  • Any fact can be misused in the service of self-punishment.
mobilizing self observing capacity
Mobilizing Self-Observing Capacity
  • Not, “Do you see how you punish yourself?”
  • Instead, “You are able to observe a reaction inside you.”
  • “There’s an awareness of something inside you that wants to criticize.”
  • “As we take a look, we can observe some urge inside you that seems to have a life of its own.”
undoing identification
Undoing Identification
  • “I punish myself” = identification = a failure in self-observation.
  • “I dreamt.” Dreaming occurred without you doing it.
  • In fact, urges occur, thoughts happen, and automatisms are activated in the patient without his will or intent.
  • We simply help him see that as a first step.
  • When a physical impulse occurs, that often signals that feeling has risen enough and defense has dropped enough that the unconscious is available.
  • “In thoughts, words, and ideas, how do you picture this impulse going out onto him.”
  • As in every other form of pressure, we will observe the response to intervention.
defense of identification
Defense of Identification
  • Rage, anxiety, identification with the object of one’s rage.
  • “I’m not me. I’m him.”
  • “I’m not terrified of him. I’m terrified of me.”
  • Manic defense against the experience of terror.
  • Unconscious form of self-punishment for murderour rage toward a predator.
adaptive function of the defense
Adaptive Function of the Defense
  • Relocate the danger within himself.
  • Control over the danger.
  • Retain hope that the father is all-good.
denial through fantasy
Denial Through Fantasy
  • Rather than relate to reality, relate to a fantasy of how you wished reality would be.
  • “You should know what you don’t know.”
  • “You should be able to do what you cannot do.”
  • “You should see what you don’t see.”
  • “You should be like someone else instead of like you.”
regressive defenses to avoid complex feelings
Regressive Defenses to Avoid Complex Feelings
  • Splitting: I will keep dad’s good qualities separate from his bad qualities.
  • Identification: I will identify with dad’s bad qualities, so he remains good.
  • Idealization: Dad is all-good.
  • Devaluation: I am all bad.
pressure to self acceptance
Pressure to Self-Acceptance
  • Superego pathology = rejecting reality, especially of you.
  • Success in therapy: successful self-acceptance of your inner life.
  • Deactivating self-rejection by inviting self-acceptance.
  • Weakening of defense = rise in feelings, and anxiety related to self-punishment.
undoing splitting
Undoing Splitting
  • Splitting: keeping opposing feelings or facts separate.
  • Undoing splitting: remind the patient of opposing feelings and contradictory facts.
  • “Pressure to consciousness.”
  • Father who saved your life, nearly took a life.
  • Father who loved, also hated.
  • Range of responses in spectrum.
process i
Process I
  • Invited portrayal.
  • Response: identification with father, splitting of mixed feelings, projection and introjection.
  • Intervention: undo all defenses until the patient can bear mixed feelings. Then portrayal will be possible.
  • Undo defenses.
  • Response: rise of grief.
process ii
Process II
  • Intervention: invite acceptance of his ‘inner panther.’ Invited him to face rage toward father.
  • Response: identification with father, splitting, and introjection.
  • Intervention: undo splitting.
  • Response: ability to bear complex feelings without splitting. Understanding clear.
pathological mourning
Pathological Mourning
  • Freud: Rage toward lost figure; anxiety; identification with the figure.
  • “I did not want to kill you; I want to be you.”
  • “I have not lost you; I am you.”
  • Defense against rage and grief; simultaneously allows self-punishment by turning rage onto oneself.
  • Pathological mourning must be addressed first for rage to become accessible.
smile as a character defense
Smile as a Character Defense
  • By smiling, I reject my feelings.
  • By smiling, I am cruel and dismissive to myself.
  • By smiling and cynicism, I hide my love.
  • By hiding my love, I hide my grief.
identification as a defense
Identification as a Defense
  • Murderous rage toward father triggers guilt toward a loved one.
  • Rather than bear the guilt, he punished himself.
  • “I must eat his sins forever to atone for my own sin of wanting to kill him. And through my sin eating, I will prove my love.”
  • To undo splitting, important that he can feel compassion for his father and for himself.
  • Otherwise, “I feel compassion for me but not for him, is another form of splitting.”
  • Likewise, “I feel compassion for him, but not for me,” is also splitting.
compassion for the origin of the defenses
Compassion for the Origin of the Defenses
  • Self-judgment of his defenses merely perpetuates the self-rejection of superego pathology.
  • Point out the adaptive function of his defenses to undo his self-rejection and increase his self-acceptance.
  • Patients can easily misuse defenses for the purpose of self-hatred as if that is therapy.
compassion for self acceptance of reality
Compassion for Self = Acceptance of Reality
  • “You did what you could do and that was all you could do.”
  • “Yes. You managed it terribly. And it sounds like that was the best you could do at the time: terribly.”
  • “You didn’t know what you didn’t know.”
  • “You didn’t see then what you see now.”
portrayal and pathological mourning
Portrayal and Pathological Mourning
  • Defenses can arise which prevent the mourning process from unfolding.
  • Note all resistances to saying goodbye.
  • Note all attempts to bury his internal life, to remain dead with the lost figure and thus avoid loss and punish himself.
undoing splitting and denial
Undoing Splitting and Denial
  • Undoing splitting allows the patient to experience complex, mixed feelings toward his father.
  • Undoing denial allows the patient’s repressed feelings to finally rise to the surface.
  • Offers a coherent narrative of the patient’s inner and outer lives.
  • Describe the process of the session in terms of the triangle of conflict.
  • Show causality: feelings, anxiety, and the defenses which caused his presenting problems.
  • Make sure patient understands what the two of you have learned together.
one year follow up
One Year Follow-up
  • “My legs are perfectly responsive to sensation in every place. Nobody understood why this is the case.”
  • “The staff at [rehabilitation center] had me dance on a cushioned pad for one half hour…They were dumbfounded that my balance was so good.”
  • “That was a watershed day for me. The result was truly miraculous for me in my opinion.”
  • Go to for articles, blogs, dvds, skill building audio studies, and webinars on ISTDP.
  • Co-Creating Change: Effective Dynamic Therapy Techniques, May 2013. Seven Leaves Press.
  • Go to for answers to your clinical questions.