Is There Still a Role for

Abreaction?
Presenter: Norman A. Poole, MD, FRCPsych, MSc
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June 10: Hypnosis and FND
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Alfonso Fasano, MD, PhD
Is There Still a Role for
Abreaction?
Presenter: Norman A. Poole, MD, FRCPsych, MSc
 TERMINOLOGY

Nembutal
Amytal interview Narco-analysis Narcosynthesis
hypnosis

Narcocatharsis Narcosuggestion Narcoplexis Hypnoanalysis

Abreaction
 • Loevenhart (1916) observed mute
patients replied to questions after
hyperventilating sodium cyanide
• Bleckwenn (1929) used sodium amytal to
induce “deep sleep” in patients with
schizophrenia
• Noticed a “lucid” period shortly before sleep
ORIGINS and again upon waking. Patient able to
discuss emotionally sensitive topics and
future plans
• Guttman (1936) used mescaline on a
variety of patients and controls
• “There is reason to suppose that patients in
such a state may be very susceptible to
psychotherapeutic influence ... If it is so, the
intoxication could be made use of as a sort
of forced or concentrated analysis”
 • Sargant & Slater published Acute War
Neurosis in the Lancet (1940)
• Horsley published Narco-analysis
(1943).
• He began by using nembutal during
investigation of “amnestic childbirth”.
Patients observed to be unusually
“cooperative and candid” followed by
ORIGINS complete amnesia.
• Suggested that “narcosis” similar state
to hypnosis
• Pathogenic suggestibility
• Therapeutic suggestibility
• ie improved rapport and
memory
 • Sargant & Slater published Acute War
Neurosis in the Lancet (1940)
• Horsley published Narco-analysis
(1943).
• He began by using nembutal during
investigation of “amnestic childbirth”.
Patients observed to be unusually
“cooperative and candid” followed by
ORIGINS complete amnesia.
• Suggested that “narcosis” similar state
to hypnosis
• Pathogenic suggestibility
• Therapeutic suggestibility
• ie improved rapport and
memory
 • Narco-analysis said to “loosen
psychic tension”.
• The clinician was able to
overcome resistance and negative
transference.
ORIGINS • Patients made remarks during the
interview that could later be
analyzed within formal
psychotherapy.
• A short cut!
 • Narco-analysis said to “loosen
psychic tension”
• The clinician was able to
overcome resistance and negative
transference
ORIGINS
• Patients made remarks during the
interview that could later be
analyzed within formal
psychotherapy
• A short cut! Not the “Royal Road”
to the unconscious mind, but a
“back alley”
 • WWII
• Acute war neurosis (often
hysterical) “almost as urgent as
that of the acute abdomen”
(Horsley, 1943)
ORIGINS • Required rapid assessment and
return to the front if possible
• Narco-analysis requires no skill in
hypnosis and should be performed
by an officer in casualty as soon as
practicable (Sargant, 1942)
 • Used in:
• Differentiating between organic and
psychiatric conditions
• Recovery / reintegration of memory
• Abreaction of trauma

ORIGINS • Treating catatonic mutism

• Differentiating “hysteria” from
malingering, symptoms worsening
in the latter
• “The future of narco-synthesis is
infinite and the possibilities
endless” (Tilkin, 1949)
 THEORY

• Charcot conducted uncontrolled experiments on “hysterical”

symptoms using hypnosis and magnets
• Charcot considered hypnotic state similar to “hysteria”
• Babinski preferred the name “Pithiatisme”
• Janet: Hypnosis also considered a state of dissociation and
enables access to the dissociated (“hysterical”)
functions/ideas
• Both the hysterical and hypnotized are highly suggestible
• Suggestibility a special instance of dissociation
• “In suggestion, each idea seems to develop to the
maximum, to give all it contains in the way of images,
muscular movements and visceral phenomena”
 • Freud and Breur initially proposed an
“electrical” model of conversion
symptoms.
THEORY • Energy of strong affect-idea converted
into neurological symptoms.
• Observed that as patients identified and
spoke about affect-idea their symptoms
improved.
 THEORY

Freud and Breur initially proposed an

“electrical” model of conversion symptoms.
 Energy of strong affect-idea
converted into neurological
symptoms.
 Observed that as patients identified
and spoke about affect-idea their
symptoms improved.
 William Brown (1919) believed rapid
revival of memories considered key to
therapeutic success in “shell shock of
the hysterical type.”
 Gain consent (informed?)

Induction

• Sodium Amytal 500mg in 10ml.

• Other agents used too.
METHOD • Inject at 1ml per minute
• Note respiration and corneal
reflex
• Two doctors present + Ambu
bag + airway
• Alternatively; 5mg lorazepam
in 20mls
• As above plus Flumazenil.
 Begin interview by
talking about effects of
medication and Ask about neutral details of
feelings of relaxation personal history

Watch for sighing Tentatively approach events

leading up to onset of
symptoms
METHOD
Exploration Allow to talk

If able to recall details give

suggestions that will be able
to recall these on waking

NB Not a “truth
serum”
 Other techniques used
during narco-analysis:

• Abreaction/ cathersis
• Suggestion
METHOD • Rehabilitation
• Video & replay

Usually a combination
of two or more
employed.
 Adverse reactions

• Acute aggression
• Respiratory depression

METHOD Contraindications

• Hypersensitivity to agent
to be used
• Porphyria
• Cardiac arrhythmia
• Acute intoxication
THEN….
 Lack of evidence for efficacy

Other treatments became available

Doubts over validity of diagnosis

CRITICISMS Based on out-dated “philosophy of

mind”

Danger of false-memory syndrome

Ethically dubious

Fears about safety

 R ES EA RCH
O N O TH ER
TH ERA P EU T I
C
I N TE RV I E W S
M E TA - A N A LY S I S
OF CASE
R E P O RT S
(2010)
 RESULTS

• The median age of participants was 29 years (range 10–74), and the mean duration
of symptoms 49 days (range 3–3650).
• However, nearly a third of studies failed to report the duration of symptoms.
• Two of the largest studies utilised drug interviews only in those unresponsive to standard
therapy; both reported very high response rates.
• Suggestions are verbal communications that a specific non-volitional response will
be experienced by the recipient. These communications are statistically associated
with a good outcome in the meta-analysis; employed in all of the large studies
• The drug interview was originally developed as the first step in a treatment regimen
rather than an entire therapy of itself.
• The absence of rigorous randomised controlled trials indicates that the declining use
of abreaction as a treatment for conversion disorder has not been an evidence-based
decision. .
THERAPEUTI
C S E D AT I O N :

THE GOOD
GUISE
 THERAPEUTIC SEDATION

• Propofol infusion, administered by anaesthetist

• Chosen for its pleasant anxiolytic effects, and rapid correction of oversedation
• 11 case (55% response rate)
• 3 became asymptomatic
• 3 major improvement
• 2 minor improvement within 24 h of sedation
• 2 improved only during the sedation itself but relapsed
• No change in one bedbound subject
• No adverse events associated with the procedure
• At median follow up of 30 months (range 1–120 months) all improvements were
maintained. Two patients who were “cured” and two patients with major
improvement during sedation sustained this improvement over lengthy follow up
• Procedure said to work best those with a good understanding of the condition,
rationale for treatment, and unambiguous evidence of motivation to improve
 Demonstration of
reversibility (like Hoover’s
sign but for paraplegia or
dystonia)

SUGGESTE
A powerful method of
suggestion/ placebo D MODE OF
ACTION

A chemically altered brain

state inducing temporary
interruption of altered
cognitive, motor and
emotional pathways
 • Barbiturates / benzodiazepines induce
calm, altered consciousness, inattention
to surroundings and increase
suggestibility
• Act on GABAA
• -1 predominate in cortex & thalamus,
cause sedation
• -2 & -5 predominate in limbic system
and potentiation is anxiolytic
PSYCHOPHARMACOLOGY
• Propofol
• Also acts on GABAA
• Inhibits DMN (but post cingulate and
ant-med PFC to lesser degree)
• Decreased thalamic connectivity with
DMN and salience network, while
increasing connectivity with sensorimotor
and auditory/insular cortices
Re-emerging
interest
•Psychedelic drug +
(brief) psycho-therapy:
• Ketamine
• LSD
• Psilocybin
• (Little said about the
psychotherapy)

•For treating anxiety,

depression and
trauma
•FND suggested as
potentially treatable
• FND:
• Aberrant somatic self-representation - through
heightened self-monitoring - exerts excessive
influence over normal motor function
• Psilocybin
• 5-HT2A agonists induce a reduction in fMRI
activity and functional connectivity within
higher-order modules including the DMN.
• Reduction correlates with the intensity of ego
dissolution, consistent with their role sustaining
self-related cognition
• Neural activity in frontal regions said to exert
less constraint over lower-order centro-posterior
regions
• Lower-order regional activity exerts greater
influence over higher-order areas., a reversal of
normal hierarchical brain dynamics.
 NEJM (2021):
PSILOCYBIN VS.
C I TA L O P R A M
C A R H A R T- H A R R I S E T A L
 • Section S2.8.3. Preparation Sessions (one day prior to the first psilocybin session)
• Preparation sessions lasted for 3 hours in total. The main guiding premise was that emotions are a
navigational system that can lead the experiencer towards a sense of greater understanding, meaning
and purpose; i.e., by going towards (rather than away from) painful content, many important lessons
can be learned. In the session, participants were encouraged to discuss with their guides any memories
and emotions they tend to avoid rather than confront, and they were encouraged to fully embrace and
explore them, should they arise during the upcoming psilocybin session.
• Participants were also encouraged to verbalise a sense of intention for why they were engaging in this
work. They then engaged in a visualisation exercise to strengthen their skills of accepting challenging
emotions, connecting to personal meaning and values, and ‘tuning in’ to their bodies, following the
published Accept Connect Embody (ACE) model 8.
• During this preparation session, participants and guides also conducted a practice run-through of a
psilocybin session: wearing headphones and eyeshades that would be used in the session, making
plans for how they would indicate the need for support, negotiating whether they would want to hold
the guides’ hands during onset of the drug, and practicing ways the guides could support them in
expressing strong negative emotion, should this arise.
• Prior to the second psilocybin session, the lead guide cnducted a one-hour preparation session with
the participant over Skype/telephone. Three participants who were experiencing some anxiety about
the second session opted to have this second preparation session in person.
PSYCHOLOGICAL • Section S2.8.4. In-session support
S U P P O RT • With regard to the psilocybin sessions or ‘dosing days’ themselves, emotional direction came mostly
from the ongoing music playlist that participants listened to via headphones, for the entirety of the 4-6
hour sessions. Music playlists have been previously been referred to as the ‘hidden therapist’ 12 of
psychedelic therapy, as they are known to have a strong impact on participants’ emotional responses
to psilocybin 13. For example, melancholy music often triggers the expression of grief. The playlist in
this trial included classical (Indian and Western) and ambient music and is available here
(https://open.spotify.com/playlist/1LBcs5ACHGjtmRs4vAnmLh#_=_). Both guides were present for the
entire session, usually positioned either side of the bed upon which the participant lay. The guides
would offer to hold the participants’ hands whenever they signalled a need for support or reassurance.
Conversation between guides and participants was kept to a minimum, as participants were
encouraged to direct their attention inwards. Comfortable eyeshades were provided, and participants
were encouraged to wear them as default.
• Towards the end of the session, the guides would invite the participant to share some detail about
their experience, although more in-depth discussion of session content would happen the next day.
• Section S2.8.5. Integration Sessions (one day post each psilocybin session)
• Integration sessions are referred to as ‘debriefs’ in the main paper. Both guides were present for the
in-person integration sessions, which entailed open, attentive listening to the participant’s account of
his/her session content. Participants then had the option of engaging in a visualisation exercise to
facilitate access to emotions they had experienced during the psilocybin session 8.
• Further Psychedelic Integration calls took place with the lead guide, over Skype or telephone. The first
call took place one- week post psilocybin, and up to two further calls could be conducted after each
psilocybin session. All participants opted to receive these extra calls, meaning that in practice,
 • RCTs - the procedure lends itself to
double blind controlled studies
investigating different agents and
techniques vs. placebo.

THE FUTURE • Psilocybin interviews suggest not just

placebo
• Therapist dethroned; more
collaborative
• Within context of ongoing support
 CONCLUSIONS

A once
commonly used Is it time to look
treatment has again at
almost abreaction?
disappeared.