ARTICLES

Psychodynamic Psychotherapy for Patients With

Functional Somatic Disorders and the Road to Recovery
Patrick Luyten, Ph.D., and Peter Fonagy, Ph.D.

Patients with functional somatic disorders (FSDs) are com- evidence supporting the efficacy of psychodynamic psycho-
monly encountered in clinical practice and are often con- therapy for patients with FSDs. Finally, the basic treatment
sidered difficult to treat. This article summarizes recent principles of dynamic interpersonal therapy, an integrative
advances in the understanding of these disorders that have psychodynamic treatment adapted for patients with FSDs, are
opened new avenues for treatment. Findings concerning outlined through a description of the treatment of a woman
the role of three related key biobehavioral systems (attach- with chronic widespread pain and irritable bowel syndrome.
ment, mentalizing, and impairments in epistemic trust) that
seem to be centrally involved in FSDs, as viewed from a psy- Am J Psychother 2020; 73:125–130;
chodynamic perspective, are discussed as well as empirical doi: 10.1176/appi.psychotherapy.20200010

Patients with persistent somatic complaints are commonly principles of dynamic interpersonal therapy (DIT), an in-
encountered in clinical practice. A meta-analysis (1) en- tegrative PDT. In addition, we illustrate these principles with
compassing 32 studies in 24 countries (total N=70,085 pa- a brief clinical vignette.
tients) found that approximately 30% of patients seen in
primary care fulfill criteria for somatic symptom disorder,
AN ATTACHMENT AND MENTALIZING APPROACH
and up to 50% of patients present with at least one somatic
TO FSDS
complaint. Psychotherapists often describe these patients as
“hard to reach” or difficult to treat. These labels are not The Nature of FSDs
entirely correct, however, because many of these patients are FSDs are notably heterogeneous with respect to the role of
open to psychological treatment. Recent advances in our psychological and biological factors in their development. It
understanding of these patients and their treatment suggest is therefore typically impossible to determine the relative role
that even the most severely affected patients who primarily of biological and psychological factors in an individual case.
attribute their symptoms to somatic causes can be helped We have found it crucial to acknowledge, with humility, our
with psychotherapy, including psychodynamic psychother- lack of understanding of the precise causation of a patient’s
apy (PDT). Indeed, there is increasing evidence (2–5) of the symptoms. In light of the increasing evidence of the role of
effectiveness of PDT for this patient group. A recent meta- biological factors in most, if not all, FSDs, such an attitude also
analysis (6) of 17 randomized controlled trials showed that
brief PDT was superior to minimal treatment, treatment as
usual, and the waitlist control condition, with small to large
effect sizes, and that brief PDT performed at least as well as HIGHLIGHTS
other bona fide psychological therapies. Treatment results • Psychodynamic treatment has been shown to be effective
were maintained in the long term. Moreover, there is growing in the treatment of functional somatic disorders (FSDs).
evidence (7) for the effectiveness of multidisciplinary, mul- • Recent advances in the understanding and treatment of
ticomponent, psychodynamically oriented treatment pro- FSDs from a psychodynamic perspective open important
grams for these patients. Consistent with these findings, PDT new avenues for the treatment of patients with these
disorders.
has been associated with changes in neural systems involved
in FSDs, including the stress, reward, and mentalizing sys- • Although individuals with FSDs have often been labeled
“hard to reach” and difficult to treat, this group of patients is
tems (8). heterogeneous, and many patients are open to psycho-
In this article, we provide a brief overview of psychody- logical treatment.
namic approaches to FSDs and describe the treatment

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PSYCHODYNAMIC PSYCHOTHERAPY FOR PATIENTS WITH SOMATIC DISORDERS

aligns with our involving increasingly

current knowledge Editor’s Note: This article is part of the special issue “Consultation-Liaison Psy- desperate efforts to
of the pathogenesis chotherapy,” guest edited by Jonathan Hunter, M.D., F.R.C.P.C. Although authors find support and
of these disorders were invited to submit manuscripts for the themed issue, all articles underwent peer relief in others,
(3, 9, 10). Acknowl- review as per journal policies. deactivation of the
edging humility with attachment system
regard to the cause leading to a denial
of functional somatic symptoms characteristically has a nor- of distress and/or need for help and support, or a combi-
malizing and a validating effect on patients, who have often had nation of the two. Secondary attachment strategies are
to “prove” they are ill, have been told that their symptoms are all unconscious strategies that represent an attempt to adapt
in their head, and/or have had conflicts with health profes- to the ever-increasing threat from within that is posed
sionals about the origin of their complaints. It is therefore also by the chronic fatigue and pain associated with FSDs.
imperative to ensure that the patient has undergone thorough Although secondary attachment strategies may bring some
medical screening. short-term relief, in the long run they negatively affect the
Our approach focuses on three key areas that, in various patient’s condition and particularly the patient’s ability to
combinations, may be identified as predisposing, precipitat- seek help (including psychological help) from others and
ing, or perpetuating factors: attachment issues, capacity for to benefit from it (Figure 1). As allostatic load further
embodied mentalizing (i.e., the capacity to reflect on one’s increases, individuals who rely on attachment hyper-
own [embodied] self and others), and capacity for epistemic activating strategies desperately attempt to find support
trust (i.e., the capacity to trust others, including clinicians, as a and relief but become increasingly disappointed in others,
source of knowledge). Problems related to each of these in particular health professionals (and especially health
factors may be implicated in the development of the disorder, professionals who attempt to force a specific illness theory
but they may also result from or be exacerbated by somatic on them). For patients who primarily use attachment
complaints. There is abundant research demonstrating the deactivating strategies, feelings of loneliness and bitter-
pernicious impact of FSDs on attachment, mentalizing, and ness emerge, and the wear and tear of allostatic load on the
epistemic trust, particularly among patients whose symptoms biological stress system and psychological capacities often
have become chronic (10). lead to a complete breakdown, such that the patient feels
overwhelmed, depressed, and anxious (16).
Attachment. From a neurobiological perspective, FSDs may Among patients with premorbid attachment problems in
be best conceptualized as reflecting a state of allostatic load as particular, this process may lead to negative idealization–
a result of prolonged physical and/or psychological stress and denigration cycles. In the context of therapy, this results in
conflict (11). Allostatic load refers to a temporary or chronic intensive transference–countertransference issues, where
disruption of the dynamic equilibrium (allostasis) that char- the therapist feels either idealized, denigrated, or even ma-
acterizes the human stress response and associated neuro- nipulated. These issues seem to be largely responsible for the
biological systems (the stress, immune, and pain-regulating view that patients with FSDs are difficult to treat (17, 18). Yet,
systems) and biomediators. from the patients’ perspective, their overreliance on sec-
Attachment issues play a crucial role as either a vulner- ondary attachment strategies and the resulting behaviors are
ability factor or as a secondary factor. The attachment system an understandable adaptation strategy.
is a biobehavioral system that is centrally involved in the
stress response, as during development humans learn to seek Mentalizing. The combination of persistent somatic symp-
proximity to attachment figures when confronted with dis- toms and the use of secondary attachment strategies char-
tress. When attachment figures are available and responsive, acteristically erodes patients’ mentalizing capacities—in
the distress is typically down-regulated (Figure 1) because the particular, their capacity for embodied mentalizing. Em-
individual feels supported, cared for, and loved (12, 13). A bodied mentalizing involves the capacity to perceive and
mesocorticolimbic dopaminergic reward system underlies reflect on bodily signals (i.e., interoception) as representative
this process, as it generates the feeling of reward associated of inner mental states and one’s selfhood. Feelings of pain and
with secure attachment experiences and down-regulates the fatigue progressively impair and distort this capacity as the
stress system at both the biological (i.e., the hypothalamic- body is increasingly conceived of as a hostile entity that
pituitary-adrenal axis and the sympathetic nervous system) threatens the coherence of the self from within (19). For some
and behavioral levels (14). patients, problems with embodied mentalizing may precede
Chronic persistent somatic problems preclude the effec- the onset of FSD symptoms; in others, such problems arise
tive down-regulation of distress; proximity seeking provides, as a consequence of debilitating pain and fatigue and/or
at best, only partial relief. Hence, as the normative down- are exacerbated by these symptoms. Consistent with these
regulation of distress increasingly fails, the individual resorts assumptions, research has demonstrated problems with
to secondary attachment strategies (15). These strategies both primary or secondary alexithymia (20) and emotional
comprise either hyperactivation of the attachment system awareness (21) among patients with FSDs. Impairments in

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 LUYTEN AND FONAGY

FIGURE 1. Relationship between the attachment and stress-regulation systemsa

A B

Distress/ Distress/
fear fear

Exposure to
threat
Adverse
Activation of Activation of
emotional
– – attachment attachment
experience
Down-regulation of
emotions

Proximity Proximity
seeking seeking

a
Stress regulation system in secure attachment (A) and in insecure attachment (B).

embodied mentalizing characteristically give rise to the interpersonal dynamics can be done successfully. In DIT-
reactivation of nonmentalizing modes of experiencing the FSD, this latter focus is based on the therapist and patient
embodied self, with which clinicians working with these jointly formulating an interpersonal affective focus (IPAF)—a
patients are familiar (Box 1). description of a recurring and often unconscious pattern of
relating to the self and others that is linked to the onset and
Epistemic trust. Over the past few years, we have become perpetuation of functional somatic problems.
acutely aware of the role of problems with epistemic trust, the DIT-FSD is offered in a 16-session format or, for patients
capacity to trust others as reliable sources of knowledge about with more severe symptoms, in a 26-session format. The
the world (including knowledge about one’s symptoms) in time-limited nature of the treatment provides patients with a
FSDs. Many patients with FSDs, particularly those with a holding environment and activates the patient’s IPAF (e.g.,
history of early adversity, have had problems with epistemic “Why do I need such a long treatment? I have always been
trust before the onset of their functional somatic problems. able to take care of things on my own,” or “Sixteen sessions
These patients’ distrust of others—including health profes- will be way too short, I need many more”). Of course, at the
sionals who argue that the patients’ complaints are wholly end of DIT-FSD, some patients may benefit from longer
psychosomatic and without any biological basis—further treatment, but the aim of DIT-FSD is to empower the patient
erodes these patients’ epistemic trust. As a result, many to continue his or her own treatment process as needed.
patients feel misunderstood and invalidated (22). Hence, the In what follows, we describe the 16-session format based
first therapeutic task when working with these patients is to on a brief summary of the treatment of Linda, a woman with
validate the reality of their suffering and their symptoms. If severe and chronic gastrointestinal problems (all case ma-
this is not done, psychotherapeutic interventions will often be terial has been disguised to protect patient confidentiality).
iatrogenic because they will increase the patients’ feelings of The first phase of DIT-FSD (sessions 1–4) focuses on
invalidation and epistemic distrust (23). engaging the patient in treatment and jointly formulating an
IPAF, however preliminary, as the focus of the treatment.
Treatment Approach Linda was referred to me (P.L.) after having suffered for years
Dynamic interpersonal therapy for FSD (DIT-FSD) is an from severe and almost constant gastrointestinal problems.
integrative PDT that focuses on the three core features of She had been diagnosed as having irritable bowel syndrome
patients with FSD discussed above: the activation or reac- and chronic widespread pain, and she had undergone nu-
tivation of secondary attachment strategies to deal with merous medical tests and examinations in the past. Each time,
persistent somatic problems, the resulting impairments in she was told that her condition must largely be stress-related
embodied mentalizing, and problems with epistemic trust and that she needed to see a psychologist or psychiatrist.
(9, 24). During her intake interview, Linda told me that she had
Because patients with FSDs are notably heterogeneous seen several psychologists, but none of them seemed to have
with respect to the nature and origins of their problems, the understood her; they all seemed to agree with the view that
ability to tailor treatment to patients’ needs and capacities is a her symptoms and complaints were largely psychological.
central feature of DIT-FSD. For patients with more severe Each time, after a few sessions, she terminated treatment.
impairments in embodied mentalizing, therapy typically In DIT, this narrative is seen as a cautionary tale: the pa-
focuses on reactivating the capacity for embodied mental- tient warns the therapist of not only what might reoccur in
izing before any work focusing on the content of the patient’s the therapeutic relationship (“people, including you as a

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BOX 1. Typical nonmentalizing modes among patients with functional somatic disorders

Psychic Equivalence Mode • Therapeutic response: validation, then focus on the embodied
experience of feelings related to somatic problems and how
• Inner (mental) and outer reality are equated (“I think there is a
these feelings relate to current (interpersonal) problems
virus causing my problems, so there must be a virus causing my
through the process of “microslicing.”
problems”).
• Therapeutic response: validating the patient’s perspective Pretend Mode
while recognizing uncertainty and humility with regard to the • The patient’s thoughts and feelings become decoupled from the
precise causes of somatic problems. external world and may give rise to excessive rumination and even
dissociation of thought (hypermentalizing or pseudomentalizing).
Teleological Mode • Therapeutic response: “rewinding” to when the patient lost the
• Only observable causes (e.g., severe physical abuse) or capacity to mentalize and explore what interpersonal situation
biological factors (e.g., a virus, tumor, or poisoning) can cause was reactivated that led to the loss of mentalizing (e.g., “I felt
psychological and/or somatic complaints. rejected again” or “I felt humiliated”).

therapist, do not understand me”) but also of what might mother and her gastrointestinal symptoms, but that in the
happen if the therapist is yet another person who does not here-and-now of the session, she felt that there must be a link
understand her (she will end the treatment). Because this between the two.
template or pattern might also prove to be a central com- In DIT-FSD, we do not force a specific illness theory on the
ponent of Linda’s IPAF, my initial response was to validate patient, but use interventions aimed at fostering embodied
and normalize her adaptation strategy, expressing my sur- mentalizing so that the patient begins to experience possible
prise that both physicians and psychologists had not taken her links between a repetitive interpersonal pattern and somatic
seriously and saying that it must have been terrible given that symptoms through “microslicing” of interpersonal events
she clearly was in pain and feeling desperate. In response, she (i.e., exploring undifferentiated mental states in relation to
started to cry. She then looked up and asked me whether I interpersonal events in a step-by-step manner to break them
believed her. I told her that she did not need to convince me of down into specific mental states that are meaningfully linked
the reality of her symptoms or of her feelings of desperation to each other). This experience led Linda to talk about other
and depression because no one seemed to be able to help or relationships in which this anxious pattern of wanting to be
even to understand her. the one who is preferred over others had recurred (with a
Hence, my empathic validation of her feelings of in- teacher, with a man who gave her lessons at a pony club, and
validation and recognition of the reality of her suffering led to with two boyfriends she had dated before meeting her cur-
a relaxation of her epistemic vigilance and the emergence of rent partner). In her current relationship, she said that this
an interest in what else I thought about her and her problems. pattern seemed to be somewhat less important because her
Together, we were then able to discuss whether she had partner was “extremely patient with her” (which could also
experienced the feeling of not being understood before. This be read as a cautionary tale).
exchange led to an attachment memory: as a child, Linda In session 3, we were able to jointly arrive at a preliminary
always had the feeling that she was “second best” and that formulation of her IPAF. She saw herself as someone who was
her parents, particularly her mother, preferred her sister. always there for others, caring for and helping them. How-
Throughout her childhood and adolescence, she had always ever, she experienced others as being uncaring and as pre-
attempted to be her “mother’s darling,” but she always ferring other people, despite doing her utmost to please them.
seemed to fail to surpass her sister in this regard. She became This experience made her feel sad, lonely, and despondent,
desperate for her mother’s attention and felt very anxious but also highly anxious because it meant, in her experience,
whenever her mother seemed to disapprove of something that no one really cared for her and that she was “all alone in
that Linda did or wanted. When she was 10 or 11, Linda began the world” (an example of psychic equivalence functioning).
to develop gastrointestinal symptoms. When I asked how she Importantly, we were able to consider this pattern as an
felt as a child and as a teenager, Linda responded that she felt understandable adaptation strategy given the context in
constantly anxious and on guard. When I asked whether which she grew up. However, this strategy also had a large
these feelings also may have taken a toll on her body (i.e., an emotional and somatic cost: not only did she feel anxious and
embodied mentalizing focus), she responded that this was alone, she always felt tense and on guard, and she always felt
true: she always felt tense, as if there was a weight on her as if there was “something on her stomach,” giving her
shoulders and a constant pressure in her stomach. I asked cramps.
whether she now felt the same tension and pressure during When we focused on her cramps and the feeling that
the session. Linda responded that she had never thought of there seemingly was always “something on her stomach,” she
the connection between her anxious preoccupation with her could, at first very cautiously and with a lot of shame,

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 LUYTEN AND FONAGY

acknowledge that she also often felt frustrated and angry process of change after the treatment ends. The ending phase
because others neglected her and did not understand her. She typically starts by the therapist sharing a draft “goodbye”
recalled, for instance, how one day when her sister had or- letter that contains an overview of the patient’s presenting
ganized a barbecue for the whole family, Linda had felt so problems, the jointly agreed upon IPAF formulation, the
tense, frustrated, and angry that she had to leave early because changes that have been achieved in treatment, and a summary
she felt nauseated and had to vomit. She had left the barbecue of what remains to be achieved. The patient is then invited to
without telling anyone and without mentioning that she felt read the letter out loud and to suggest any changes that he or
unwell. Hence, her feelings of anger and frustration typically she feels are needed. The letter provides another important
gave rise to high levels of bodily arousal and tension, which opportunity to work through the IPAF because it typically
contributed to her gastrointestinal problems. Feelings of guilt reactivates the patient’s IPAF. Linda, for instance, became
inhibited her anger until the whole cycle started again. Linda, silent when handed the letter. She read the letter, seemingly
however, had always attributed her cramps to a somatic cause without any emotion, and said she did not have any comments
(an example of teleological functioning). on it. When I asked whether the letter conveyed the work that
The second phase of DIT (sessions 5–12) involves a we had done together, she nodded. However, because she
constant focus on how the IPAF recurs in the patient’s life. In knew the letter introduced the last phase of treatment, she
addition, once the therapy has strengthened the patient’s added that it left her feeling that I had probably had enough of
capacity to reflect on the negative impact of this repetitive her and wanted to get rid of her because there must be other,
pattern of thinking and feeling and its link with presenting more interesting, patients who wanted to see me. When I
symptoms, the therapist and patient can jointly begin to suggested that perhaps this was Linda’s old pattern being
consider alternative ways of relating to the self and others. reactivated, she nodded and said she was surprised it could
This process is typically accompanied by an alleviation of the still be that powerful. This statement led to in-depth ex-
patient’s symptoms. ploration of how she would deal with similar experiences
Although Linda initially remained somewhat reluctant to when her old pattern might be reactivated in the future. Much
talk about her family and current relationships, she in- of the final few sessions was used to examine the extent to
creasingly began to acknowledge—first during the sessions which the old pattern remained active in her daily life and the
and then, as the treatment progressed, in the wider world— extent to which she had already internalized other ways of
how her feelings of not being seen or understood weighed on looking at herself and others. By the end of the treatment, she
her both symbolically and literally. In other words, she ac- was able to express gratitude toward me and the treatment;
knowledged how she had always felt oppressed and sup- although she still had occasional gastrointestinal problems,
pressed and how these feelings had led to a constant state of her symptoms had become markedly better. In the final
anxious tension. The emotional and physical costs of her session, she wanted to discuss whether her symptoms had
expectation that others would not be there for her and that biological roots and therefore might never resolve com-
they preferred others above her became increasingly clear. At pletely. She said she remembered that during our first
this point in the therapy, both her general feeling of being session, I had said that I believed her symptoms were real
tense and her more specific gastrointestinal problems began and not imagined and that this had given her the feeling
to improve markedly. Not only did she feel less of a need to be that I was truly listening to her and thus that I could help her
“preferred” by others, she reported feeling more relaxed in (an example of the restoration of epistemic trust).
the company of others. In addition, her almost endless
worrying that others did not like her because of something
CONCLUSIONS
she said or did not say, or did or did not do (which led to
anxious thoughts about rejection and abandonment that For many years, patients with FSDs were often considered
often preoccupied her for days, an example of pretend mode hard to reach and difficult to treat. However, these labels
functioning) considerably decreased. The fact that her neglect the fact that this group of patients is heterogeneous
partner continued to be supportive and reassuring played an and that many of these patients are open to psychological
important role in this context. She also began to distance treatment. Moreover, the perception of a subset of these
herself more from her mother and sister and from friends patients as being hard to reach primarily resides in the eye of
whom she felt exploited her tendency to care for others and the beholder (i.e., medical professionals and therapists).
always be there for them. In the middle phase of treatment, Many of these patients have grown up in an invalidating,
DIT uses the full spectrum of interventions typically used in traumatizing environment in which epistemic distrust and
PDT. This spectrum includes supportive interventions when hypervigilance were, at least in the short term, adaptive.
needed, interventions that foster embodied mentalizing, Combined with often severe attachment disruptions and
insight-oriented interventions (i.e., clarification, challenge, impairments in embodied mentalizing, this adaptation
and interpretation), and directive interventions to encourage strategy increasingly gives rise to considerable psychological
the patient to bring about changes related to their IPAF. and metabolic costs, particularly when combined with bi-
In the ending phase (sessions 13–16), the focus is on ological vulnerability. Moreover, invalidating responses by
empowering the patient so that he or she can continue the others, including mental health professionals who often

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PSYCHODYNAMIC PSYCHOTHERAPY FOR PATIENTS WITH SOMATIC DISORDERS

(even with good intentions) attempt to force specific illness 9. Luyten P, Van Houdenhove B, Lemma A, et al: Vulnerability for
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symptoms”) on these patients, further increase the patients’
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