Dynamic therapies

Short-term dynamic therapies such as emotional awareness and expression therapy (EAET) and intensive short-term dynamic psychotherapy (ISTDP) explicitly target emotional and interpersonal processes that are known to transcend diagnostic boundaries (Maroti Reference Maroti, Frisch and Lumley2025). While cognitive–behavioural approaches emphasise catastrophic interpretations, symptom vigilance and behavioural avoidance, dynamic therapies focus on unresolved emotional experiences, internal conflicts and defensive patterns that modulate autonomic arousal and shape bodily expression. Many patients with PPS have long-standing tendencies to inhibit anger, grief or shame in significant relationships, often accompanied by unprocessed chronic role-based stress or interpersonal ruptures. These themes align with the emotional and physiological contributors identified by Felton et al, but they highlight different mechanisms for symptom persistence and change.

Evidence supporting these emotion-focused mechanisms in PSP comes from both clinical trials and process research on EAET and ISTDP (Abbass Reference Abbass, Lumley and Town2021; Maroti Reference Maroti, Ljótsson and Lumley2021). For example, in three randomised controlled trials of EAET for people with chronic primary pain, EAET outperformed traditional cognitive–behavioural therapy (CBT) on pain reduction (Lumley Reference Lumley, Schubiner and Lockhart2017; Yarns Reference Yarns, Lumley and Cassidy2020, Reference Yarns, Jackson and Alas2024). Across these trials, 30% of participants reported a 50% pain reduction. Although not directly compared with the transdiagnostic CBT model described by Felton et al, the results highlight the potential of a direct focus on internal emotional conflicts. Moreover, in mediation analyses, including symptoms beyond pain, such as gastrointestinal symptoms or fatigue, increased capacity for emotional processing partially accounted for subsequent improvements in somatic symptoms (Maroti Reference Maroti, Ljótsson and Lumley2021, Reference Maroti, Lumley and Schubiner2022). These results underscore that processes of emotional change may constitute a core transdiagnostic pathway in their own right. Although these findings resonate with Felton et al’s emphasis on emotion dysregulation, they suggest that emotional activation and integration may play a more central mechanistic role than the transdiagnostic cognitive-focused model Felton et al suggest.

Reasons to expand the transdiagnostic perspective

Felton and colleagues correctly identify cumulative stress exposure as relevant to symptom development, but relational stress is described primarily as an external trigger rather than an ongoing, internalised pattern that continuously shapes physiological arousal. Dynamic therapies view interpersonal patterns not merely as environmental factors but as emotionally charged templates that influence how individuals perceive, regulate and express core affects. For many patients, the bodily symptoms that bring them to treatment are closely linked to relationship-based conflicts or inhibitions that have persisted for years. Addressing these interpersonal dimensions directly – rather than treating them as contextual variables – may enhance the effectiveness of transdiagnostic interventions.

Another reason to expand the current framework is the level of mechanistic specificity that modern dynamic treatments have achieved. Contemporary short-term psychodynamic approaches operationalise emotional change in ways that parallel the precision of cognitive–behavioural models. EAET involves systematic identification and processing of avoided emotional experiences. ISTDP employs moment-to-moment tracking of anxiety, defences and affective responses to facilitate emotional integration and reduce somatic discharge. Both therapies delineate mechanisms that converge with the emotion dysregulation pathways presented in the article, but offer additional detail regarding how these emotional states originate, why they persist and how they become embodied. Beyond expanding the theoretical understanding of how emotional conflicts that generate anxiety and defensive processes influence the development and maintenance of PPS, short-term dynamic therapies offer specific techniques for identifying and resolving such conflicts.

Clinical and research implications

Expanding the transdiagnostic perspective to more fully include emotional and interpersonal processes does not diminish the importance of cognitive and behavioural mechanisms. Instead, it allows for a more pluralistic understanding that reflects the multifaceted nature of PPS. In clinical settings, patients rarely present with problems that map neatly onto a single theoretical model. Cognitive distortions, emotional inhibition, defensive avoidance and relational stress often operate together. For this reason, clinicians may benefit from assessing which mechanisms are most salient for a given patient and selecting interventions accordingly – whether they stem from cognitive–behavioural, psychodynamic or other traditions. In clinical practice it may be particularly useful to incorporate contemporary psychodynamic perspectives into the multifaceted treatment of PPS for patients whose symptoms appear to fluctuate with emotional states or when defensive processes hinder therapeutic progress.

There are also implications for future research. Mechanistic studies in PPS have historically focused on cognitive and behavioural mediators, yet growing evidence suggests that emotional mechanisms warrant equal attention. Mediation and process analyses incorporating emotional conflict, affect tolerance, defensive functioning and relational stress could deepen our understanding of how diverse therapies produce change. Such work would complement, rather than compete with, cognitive–behavioural research and support the development of comprehensive transdiagnostic models.

Felton and colleagues have provided a valuable overview for clinicians and researchers. Our hope is that future elaborations of transdiagnostic frameworks will more explicitly include emotion-focused and interpersonal processes, not only as contributing factors but as central pathways through which symptoms persist and change. The integration of cognitive, behavioural, emotional and relational mechanisms may ultimately lead to more personalised and effective treatment options.