Identifying attachment ruptures underlying severe music performance anxiety in a professional musician undertaking an assessment and trial therapy of Intensive Short-Term Dynamic Psychotherapy (ISTDP)

Introduction Kenny has proposed that severe music performance anxiety that is unresponsive to usual treatments such as cognitive-behaviour therapy may be one manifestation of unresolved attachment ruptures in early life. Intensive Short-Term Dynamic Psychotherapy specifically targets early relationship trauma. Accordingly, a trial of Intensive Short-Term Dynamic Psychotherapy with severely anxious musicians was implemented to assess whether resolution of attachment ruptures resulted in clinically significant relief from music performance anxiety. Methods Volunteer musicians participating in a nationally funded study were screened for MPA severity. Those meeting the critical cut-off score on the Kenny Music Performance Anxiety Inventory were offered a trial of Intensive Short-Term Dynamic Psychotherapy. In this paper, we present the theoretical foundations and rationale for the treatment approach, followed by sections of a verbatim transcript and process analysis of the assessment phase of treatment that comprised a 3-h trial therapy session. Case description The ‘case’ was a professional orchestral musician (male, aged 55) who had suffered severe music performance anxiety over the course of his entire career, which spanned more than 30 years at the time he presented for treatment following his failure to secure a position at audition. Discussion and evaluation The participant was able to access the pain, rage and grief associated with unresolved attachment ruptures with both parents that demonstrated the likely nexus between early attachment trauma and severe music performance anxiety. Conclusion Intensive Short-Term Dynamic Psychotherapy is a potentially cost-effective treatment for severe music performance anxiety. Further research using designs with higher levels of evidence are required before clinical recommendations can be made for the use of this therapy with this population.


Background
has identified three possible subtypes of music performance anxiety-(1) focal anxiety associated with realistically highly anxiety-provoking situations such as auditions and solo performances with little generalized anxiety to other situations; (2) performance anxiety associated with a comorbid diagnosis of social anxiety (social anxiety disorder); and (3) performance anxiety associated with severe, performance-impairing anxiety, co-occurring with panic and either pervasive dysthymia, dysphoria or depression. Kenny hypothesized that an unresolved attachment disorder was implied in the majority of subtype 3 and may be implicated in subtype 2 to a lesser extent, with attachment ruptures occurring later in childhood than in subtype 3. Subtype 3 has been referred to as a disorder of the self (Kohut 1971(Kohut , 1977(Kohut , 1984Kohut and Wolf 1978), pre-verbal trauma (Winnicott 1945(Winnicott , 1965(Winnicott , 1974; (reactive) attachment disorder (Fonagy and Target 1997;Halpern 2004;Janus 2006;Mills 2005;Wallin 2007) and fragile character structure (Davanloo 1990(Davanloo , 2005. Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a short term psychotherapy that shares with other short term psychotherapies a number of common features, which include time-limited contracts, maintaining a therapeutic focus (as opposed to the free association of psychoanalysis), active therapist involvement (as opposed to the non-intrusiveness of analysts), and the use of the transference relationship involving the Triangle of Conflict (feelings/impulse, anxiety and defence) (Ezriel 1952) and the Triangle of Person/Time (past relationships, usually parents, therapist and current relationships) (Menninger and Holzman 1973) to maintain the therapeutic focus (Davanloo 1990(Davanloo , 2005. For a detailed explanation, see Kenny (2011).
The theoretical structure of ISTDP draws on Freudian psychoanalysis (Freud 1933), attachment theory (Bowlby 1988;Schore 2003), and the short-term psychotherapies (Malan 1979). The core therapeutic action in ISTDP is the "patient's actual experience of his true feelings about the present and the past" (Davanloo 1990, p. 2). Davanloo (1990Davanloo ( , 2005 developed a technique to rapidly mobilize the unconscious therapeutic alliance (Davanloo 1987) in order to remove the major resistances to change, which were not effectively removed through interpretation alone.
Internal emotional conflicts are created through ruptures in attachment relationships in the first 8 years of life (Bond 2010;Muller 2009;Pauli-Pott and Mertesacker 2009). Many are due to chronic parental misattunement to, or lack of empathy with children's emotional signals. The age of the child at the time the rupture first occurs, and the frequency and duration of these experiences of rupture are indicators of the severity of the attachment rupture (Bond 2010). The younger the child, the more frequently the events occur and the longer the overall duration of the events, or the more persistent and unrelieved the parental misattunement, the more severe is the attachment rupture (Beebe et al. 2010;Bowlby 1960Bowlby , 1973. The rupture in the attachment relationship causes emotional pain in the child and a retaliatory rage towards the parent(s) for causing the pain. However, because the child also loves his parent(s), he feels guilt about experiencing rage towards someone he loves. The rage, guilt, grief and love are all dissociated into symptoms and are submerged under behaviours that enable the child to continue a relationship with the parent(s).This process eventually becomes a characteristic defensive system (Winnicott 1965). Whenever the child is in a situation that has the potential for a rupture of attachment, the rage, guilt, love and pain from the initial attachment rupture is re-activated. Anxiety is experienced to block the feelings from entering conscious awareness and the defensive system is automatically triggered to keep the feelings dissociated and to avoid or alter the emotionally triggering situation (Glowinski 2011). Over time, this pattern is automatically activated in any situation that has the potential to trigger the dissociated feelings about the initial attachment rupture (Amos et al. 2011), such as an evaluative musical performance.
The anxiety over the internal emotional conflict and the defensive pattern become the psychological problems in the person's life. Anxiety can manifest in four ways: (1) Tension in the striated muscles of the body, which is associated with a number of physical problems including fibromyalgia, pain, spasm, hyperventilation and panic (Abbass et al. 2006). In a therapeutic context, striated muscle anxiety is an indication that the person has the capacity to consciously experience the dissociated feelings related to the attachment rupture(s).
(2) Smooth muscle anxiety, in which anxiety is somatised into the gut, leading to gastrointestinal symptoms including nausea, reflux, cramping and the urge to urinate and/or defecate. The striated muscles remain relaxed. Chronic smooth muscle anxiety is associated with hypertension, irritable bowel syndrome and migraine (Abbass 2005;Abbass et al. 2008).
(3) Cognitive perceptual disruption (CPD). A person experiencing CPD will become confused or blank in their thoughts and/or will have disturbances in one or more of their senses when experiencing anxiety (e.g., tunnel vision, blurred vision, ringing or buzzing in the ears). Visual disturbances are most common (Davanloo 1995b). Physically, the person will appear relaxed as anxiety is not being expressed in the striated muscles, but will manifest confused thinking and not be "present" in the room. Chronic cognitive perceptual disruption is associated with neurological complaints (for which no medical cause can be found) including dizziness and fainting. (4) Conversion (Axelman 2012). Instead of becoming tense, the person will become weak in one or more limbs, experience pain in one or more areas of the body, or lose the function of one or more senses (e.g., vision). Potential medical causes must always be ruled out before concluding that the symptom is an indication of conversion.
In a therapeutic context, the experience of smooth muscle anxiety, cognitive perceptual disruption or conversion indicates that a psychological restructuring process is required before the person is capable of consciously experiencing the dissociated feelings from their attachment rupture(s).
In restructuring, the person is gradually exposed to increasing levels of anxiety via graded exposure to their dissociated feelings and helped to develop and maintain a striated muscle anxiety response (Davanloo 1995a). Eventually, the patient is able to consciously experience the previously dissociated feelings without undue anxiety. In response to anxiety, defences are automatically activated. There are three main groups of defences (Davanloo 1996); (1) Isolation of affect is the most adaptive defensive system. Patients are aware that they are experiencing a particular emotion, but they do not know how they are physically experiencing it. Instead of the physical experience of the emotion, patients with isolation of affect experience striated muscle anxiety; (2) repressive defences (Davanloo 1996). Patients with repressive defences do not recognize that they are experiencing emotions. Instead feelings are dissociated into the body. Repressive defences are linked to smooth muscle anxiety where feelings are internalized/somatised into, for example, nausea, irritable bowel syndrome, depression, headache, or conversion; (3) projective/regressive defensive system. Patients using this cluster of defences do not perceive that they are experiencing emotions, but rather perceive that another person is experiencing the feelings that the patient would be expected to feel. Typically, these patients manifest weepiness (tears without feelings of grief ), temper tantrums, explosive discharges of affect, and confusion. This defensive system is associated with cognitive perceptual disruption (Davanloo 1995b).
The combination of anxiety type and system of defence enables each patient to be located on either the Spectrum of Neurotic Character Structure (Davanloo 1999a) comprising low, moderate, and high resistance or the Spectrum of Fragile Character Structure (Davanloo 1995b).
Low resistance These patients have had secure attachment relationships for at least the first 7 years of life. Their problems are of recent onset or are mild neurotic disorders. They have no rage in their unconscious. These patients are very responsive to psychotherapy. Moderate resistance These patients have had attachment ruptures at between 5 and 7 years of age. They have character disorders and diffuse psychological symptoms, experience violent to murderous rage, guilt, and grief in their unconscious from the early attachment ruptures involving one or more figures from their early life. High resistance These patients experienced attachment ruptures in the first 2-5 years of life. They have complex character pathology and highly syntonic character resistance, with a masochistic, self-sabotaging component. These patients have intense murderous rage, guilt and grief in relation to all of their early attachment figures. Spectrum of Fragile Character Structure These patients may never have experienced an attachment bond or had their attachment bonds rupture within the first 2 years of life. They cannot withstand the impact of their unconscious feelings in the first interview and require a restructuring process where they are exposed to increasing intensities of their unconscious feelings (Davanloo 1995c). They habitually use regressive and projective defences (e.g., temper tantrums, explosive discharges of affect, self-harm, drug and alcohol misuse, dissociation, and projection).
ISTDP assists the patient to fully experience their dissociated feelings and fantasies and memories that have been dissociated with these feelings. The major interventions are applied through an over-arching framework, the central dynamic sequence (CDS) (Davanloo 1999a) that guides the therapist towards the dissociated feelings and memories. The CDS can be divided into eight overlapping stages. Each stage has definable goals that need to be achieved before progressing to the next stage. As the goals of each stage are achieved, they add to and build a complex intra-psychic and interpersonal experience during which the defences are overcome and the previously dissociated feelings enter conscious awareness. The conscious experience of these dissociated feelings triggers memories associated with early attachment ruptures, enabling these previously dissociated memories and feelings to be resolved.

Aims
The first aim of this paper was to report on the trial application of the eight stages of the central dynamic sequence of ISTDP in the first assessment session and to evaluate the degree to which early attachment trauma was present and acknowledged. The second aim was to assess the nature of the possible relationship between the attachment trauma and this musician's MPA.

Methods
The study received ethical approval from The University of Sydney Human Research Ethics Committee. The participant signed an Informed Consent allowing the researchers to videorecord and transcribe the trial therapy session and subsequent therapy (reported elsewhere: see Kenny et al. 2014a) and to write up the contents for scientific purposes.

The therapeutic intervention
There are eight key groups of interventions in ISTDP that enable the therapist and patient to achieve the goals outlined above: Stage 1: Inquiry Many patients are unable to give an accurate account of their problems. Inquiry begins to stir the unconscious and hence the activation of the defences. Stage 2: Pressure (Davanloo 1999c). Once the patient begins to resist the therapist's attempts to understand, the therapist applies pressure to the patient's feelings or defences to overcome defences sufficiently to allow the therapist and patient to understand the problem (Abbass and Town 2013). Clarification As the therapist applies pressure, the patient's defences increase. The therapist points out and clarifies the patient's defences and examines the costs of these defences. As awareness rises, the patient recognizes the costs of his defences, and begins to turn against them. This process is repeated for each observed defence. Stage 3: Challenge (Davanloo 1999b). Once the patient has turned against his defences, the therapist challenges the patient not to use his defences, but instead to experience the feelings that have been dissociated under resistance. Head on Collision (Davanloo 1999a) combines clarification of what is happening in the moment within the patient in relation to the therapist with challenge not to engage in defences, pointing out the cost to the patient in continuing the defensive pattern and placing the responsibility for change with the patient. The therapist's structured focus on the patient's feelings and defences creates complex feelings within the patient towards the therapist, called Complex Transference Feelings (CTF). The patient feels grateful to the therapist for his relentless efforts to free him from the suffering incurred through anxiety and defences while simultaneously feeling angry with the therapist for the relentless pressure and challenge to their longheld defensive system (Davanloo 1990(Davanloo , 2005. Stage 4: Transference resistance occurs when the patient resists the therapist's efforts to reach his feelings. Pressure, Challenge, and Head on Collision are repeatedly used to drive up CTF and to overcome defences as they are mobilized to the frontline of the patient's resistance. Eventually, the defences are exhausted, and the CTF are consciously experienced. Stage 5: Direct access to the unconscious. Conscious experience of previously dissociated feelings (rage, with guilt, grief, love and pain) being mobilised brings a desire and then a fantasy of attacking the therapist. This violent-to-murderous fantasy is the actual fantasy the patient had towards his attachment figure(s) at the time of the ruptures. After the rage, guilt is experienced about the violence/murder and the body of the therapist transfers to the injured/murdered body of the attachment figure(s). Guilt and loving feelings relating to the original attachment are felt followed by grief and pain about the loss of the attachment relationship(s). Unconscious memories now become accessible. Stage 6: Systematic analysis of the transference. The entire process, including each defence, is repeatedly recapitulated to bring the patient insight into his entire defensive system and the feelings that have been dissociated beneath the resistance. Stage 7: Dynamic exploration of the unconscious. Systematic analysis of the transference furthers access to the unconscious; the patient's memories of early attachment relationship(s) can now be examined. Meaningful insights and resolution of traumatic memories occur to the degree that the resistance to their examination has been removed (partial, major, complete) through the previous stages. Stage 8: Recapitulation, consolidation and treatment planning. Insights and understanding of how the attachment ruptures led to the development of defences to block the underlying feelings and fantasies, and how and why these defences became activated in the situations in which the patient has been experiencing problems are reviewed.
In summary, ISTDP focuses on the experience of feelings in the here-and-now of the transference. In response, the patient begins to automatically manifest anxiety and defend against dissociated feelings from breaking through into conscious awareness. This enables the therapist to assess the anxiety patterns and defensive processes of the patient in vivo. If necessary, the patient is helped to restructure his anxiety to striated muscles. The therapist continues the central dynamic sequence through one of the two routes to the unconscious, depending on whether the patient is primarily manifesting anxiety or defensiveness in the transference that block the rise of anxiety and the underlying complex transference feelings. Pressure is applied either to experience the feelings that are creating anxiety (if anxiety is in the transference), or to the defences that are blocking the rise of anxiety and complex transference feelings. This directs the resistance into the transference, paving the way for the eventual conscious experience of transference feelings and exploration of the unconscious.
In this paper, we report on the first session between the musician and the ISTDP therapist, which constituted both an assessment and a trial therapy.

Case
The participant, Kurt, 1 was a 55-year-old professional orchestral string player with one of the eight premier state orchestras in Australia. His orchestra was participating in a national study on the mental and physical health of professional classical musicians at the time of recruitment. Volunteers for the trial of ISTDP underwent in-depth interview with the first author and completed the baseline protocol comprising the Kenny-Music Performance Anxiety Inventory (K-MPAI) and tests of depression and trait anxiety reported elsewhere (see Kenny et al. 2014b). Musicians with scores on K-MPAI that were equal to or greater than 105 were eligible for inclusion in the trial therapy study (Ackermann et al. 2014).
Kurt had been a member of the orchestra for 32 years and had reached the position of assistant principal in his section. Due to the recurrent ill health of the principal, he had been called upon on many occasions to fulfil this role. He distinguished himself in the position, despite experiencing long-term severe music performance anxiety, which he had managed with a range of therapies and self-help strategies, such as daily affirmations, visualizations and meditation. He was expected to win the position when it was finally vacated by the incumbent. However, on the day of the audition, he "fell apart"-which, to most highly skilled, professional musicians means that he did not play at his best. There was no performance catastrophe or breakdown. Nonetheless, he 1 Personal details have been changed to protect anonymity. All participants in this trial had undergone previous forms of therapy without lasting success. failed to win the position. This experience motivated him to volunteer for the trial therapy study. All sessions were videotaped for later transcription and analysis.

Therapy
The second author conducted the therapy and the third author supervised the therapist. ISTDP commences with a "trial" therapy that proceeds through as many of the eight steps outlined earlier as is appropriate for the patient's level of psychological resilience. During this initial trial therapy interview, the therapist attempts to establish a working relationship with the patient by identifying any barriers to engaging in dynamic therapy, assesses the presence and type of anxiety and defences operating, and establishes the patient's goals and willingness to explore the underlying emotional issues.
Kurt's position on the spectrum of psychoneurotic disorders following trial therapy Kurt manifested striated muscle anxiety. He reported that, at times, during performances, he experienced cognitive perceptual disruption; however, he did not manifest any symptoms indicating CPD during the Trial Therapy and therefore was not placed on the Spectrum of Fragile Character Structure. Kurt built a solid "wall" of defences in the transference relationship. His primary defences were passivity, helplessness, rationalization, detachment, and turning in on himself. He responded well to intervention, turning against his defences as he saw their cost. He engaged well with the therapist to gain access to his previously dissociated emotions related to his ruptured attachments. On the Spectrum of Psychoneurotic Disorders, he was moderately to highly resistant.
This first session illustrates the various phases of the therapeutic process.
(1) Phase of inquiry The therapist explored the patient's presenting problem and ability to respond. It is a dynamic and diagnostic process that provides information about the patient's location on the spectrum of psychoneurotic disorders and the degree of resistance. The phase of inquiry can rapidly move to the phase of pressure that will continue the enquiry and reveal the nature and level of resistance likely to be encountered.

Th
What are the problems that bring you here?
[Inquiry] KURT The difference between when I practice at home, and when I actually play in an exposed situation seem to be a mountain I can sometimes climb and sometimes not… for some unknown reason it'll be okay 1 day and not the next… I meditate and I exercise a lot, I look after myself. I don't drink too much. I don't smoke… but I can't control the performance situation.
Inquiry moving into the phase of pressure In this phase, the therapist presses the patient to be more specific, to clarify the meaning of idiosyncratic or vague use of words, so will ask probing questions, and will direct focus onto the actual experience of feelings. What happens to you physically? KURT Physically, I did an audition a while ago and I lost the normal feeling in my arm. I couldn't explain it. It was like it was somebody else's arm-I couldn't control it. Th It was a feeling of complete detachment? KURT Yeah.
The therapist continues his inquiry, asking Kurt what other feelings and sensations he experienced in his body during high anxiety performances such as solos and auditions, checking for somatisation ("Do you ever get sick in those situations?") and cognitive perceptual disturbances ("Do you ever lose ability like having blurred vision?"). Kurt did not get sick but agreed that he had blurred vision when very anxious. He also gave other indications of cognitive perceptual disturbance ("Even if I know a piece or a part really well, it's almost like my brain sees it on the paper and doesn't recognize it. The message doesn't get through").
Once the therapist has a clearer picture of the presenting problem, he extends the inquiry to other parts of the patient's life. This history taking will identify the presence and extent of character neurotic process. They would have done anything to give me the job, because I was doing a good job, people told me and I knew I was doing a good job. But, unfortunately, the job gets open to anybody. I'm a bit older… The guy who got the job is terrific; I sit next to him, he's fine; I'm glad he got it. But I was slightly disappointed in myself that I didn't play as well as I could have.
(2) Phase of challenge During this phase, the therapist increases the pressure, challenging the patient to identify and turn against his characteristic defences. This sets up a conflict in the patient who is simultaneously maintaining his resistance and developing a therapeutic alliance with the therapist to relinquish his resistance. The first breakthrough occurs when the balance between maintaining resistance and unconscious therapeutic alliance with the therapist is tilted toward the unconscious therapeutic alliance. The phase of challenge begins when the patient actively resists the therapist's attempts to reach the feelings underneath anxiety. The therapist relentlessly points out the patient's defences, counters the patient's rationalizations and blocks irrelevant and distracting talk. This interchange continues for some time, with the patient continually reporting symptoms of anxiety (e.g., "I feel tight", "my breath gets shorter", "I feel tense", "I feel tight in my chest") rather than the feelings of anger underneath and the location of those feelings in his body. The therapist sums up:

Th
Underneath that anxiety how do you feel that anger toward them? …We're seeing underneath that anxiety that's crippled you and damaged you and cost you that chair, is anger, and rather than getting caught up in that anxiety it would be better to look at that anger to You've done it for a long time now; that's a big problem. You're not really looking after you. Obviously there's a part of you that wants to look after you because you're sitting here with me. (KURT: I'm here). Exactly right. So there's a healthy part that wants to look after you, but there's also this destructive part that wants to put everybody else first. That wants to rationalize your feelings, or turn them into anxiety, or turn them in on you and beat you up. All of those things are crippling your life, and we can see in that audition that the anxiety that came out of the fear of feeling your anger actually stopped you getting that job, which you'd held for 3 years, so it's a very destructive system [Again pointing out and clarifying the system of defences used to defend against hostile, angry feelings and the self-destructive consequences of such a system]. KURT Mmm. Yes, I see. Th How do you feel right now as you look That's a sabotaging part as well because whilst that wall's there I'm useless to you because it doesn't let us into where the real problems are.
[Clarifying the cost of the defence of emotional detachment] It doesn't let us resolve them. So there's a part of you that also makes people useless to you in your life, keeps them at a distance, doesn't let them be as close as they could be?
This challenge continues for some time with the therapist pointing out repeatedly how these characteristic patterns of interpersonal interaction are evident in the transference, and after seeking further clarification from the patient, in other important relationships in Kurt's life. The therapist questions, highlights, applies pressure to attend to feelings, and draws attention to the defences and to what the defences are helping the patient to avoid.

Th
These patterns have damaged you. You don't let people in or allow them to be as close to you as you want them to be. These patterns are in play here with me, trying to abandon and neglect you by putting a wall between you and me. This interchange continues, adding progressively more pressure to recognize and turn against his defences.

(3) Head on collision
This phase consolidates the challenges to the defensive system that manifest as resistance in the transference. This relentless assault on the defences that maintain the self-sabotaging, self-defeating and self-destructive stance of the patient intensifies the transference feelings and mobilizes the therapeutic alliance. At this point, complex transference feelings erupt-both anger at the pressure to give up defences and appreciation of the therapist's commitment to work with the patient.

Th
This system wants to detach you and try to make you distant, close you off and find excuses for things, rather than focus on what's going on inside. In this phase of head on collision, two separate themes run parallel-(1) not realizing his potential because of intense anxiety and (2) his defensiveness in the transference. These themes are linked: the sabotage, of which the wall is a major component, prevents him from having the life of which he is capable. The head on collision aims to intensify complex transference feelings and resistance to the point where the resistance breaks down, allowing the underlying feelings to be experienced. In the following dialogue, there is a shift away from the defences to an awareness of the sadness underneath the anxiety and anger.

Th
At Imagine the conflict in a performing artist who has been "bred" to be seen and not heard, and abused for expressing himself!

Discussion
Kurt was diagnosed with music performance anxiety; subtype 2, although there were elements of subtype 3 in his presentation. Kurt reported generalized social anxiety, particularly in groups, as well as panic that resulted in his sitting still and shutting up, behaviours akin to a "freeze" response seen in extreme anxiety. Although Kurt reported some symptoms of cognitive perceptual disruption (blurred vision) and conversion (his bowing arm felt "like somebody else's arm"), he did not display these in the therapy setting and was therefore not placed on the fragile character spectrum.
In this 3-h trial therapy of ISTDP, Kurt was able to access anger, guilt, pain and grief regarding his difficult childhood; that is, the emotional content of his attachment ruptures that had been defended against all of his life, but which broke through in conditions of stress, such as musical performances. He was able to make the link between his resistances and destructive defensive system to acknowledge his painful feelings as the source of his anxious musical performances.
The ISTDP therapist constantly tracked the emotional state of his patient, assessing the quality of the therapeutic alliance and the level of anxiety that inhibited exploration of the patient's habitual defensive patterns. By the time adults come into therapy, their defences are experienced as ego syntonic and when challenged, vigorously defend their defensive systems. The central dynamic sequence was applied repeatedly throughout the trial therapy to gain further access to the core psychopathology. Many of the phases of ISTDP were achieved in this session, indicating that Kurt was a suitable candidate for ISTDP. The patient subsequently successfully completed ISTDP, which resolved his music performance anxiety (Kenny et al. 2014a).

Conclusion
To date, the treatment of choice for MPA has traditionally been combinations of the behavioural and cognitive therapies (CBT). The caseload from which this case was drawn comprised musicians who had previously attended unsuccessfully for other therapeutic interventions that included CBT, mindfulness-based programs, Alexander Technique, and biofeedback training. Detailed psychotherapy process reports of the application of ISTDP to the treatment of severe music performance anxiety are needed to advance the investigation of suitable therapies for the treatment of severe MPA.