Panic-Focused Psychodynamic Psychotherapy

Both cognitive-behavioral^1-3 and pharmacological^4-6 treatments for panic disorder have been found to be effective over the short term. Not all patients, however, can tolerate or fully respond to these approaches,^1-3,7,8 and the effectiveness of these interventions over the long term remains unclear.^1,9 The degree to which these treatments affect psychosocial and quality-of-life impairments associated with panic disorder is uncertain because of limited data.^10,11 Given the high level of associated morbidity and health costs, it is important to continue to develop and study additional treatments for panic disorder.^12-15

Psychodynamic psychotherapy is a widely used treatment for panic disorder, but it has received little systematic assessment.¹⁶ The authors have developed a manualized version of psychodynamic psychotherapy called panic-focused psychodynamic psychotherapy (PFPP).¹⁷ PFPP differs from nonspecific psychodynamic psychotherapy in its focus on symptoms and dynamics of panic disorder. In a recent randomized controlled trial,¹⁸ PFPP demonstrated efficacy for panic disorder in comparison to a less-active psychotherapy called applied relaxation training (ART).¹⁹ This study was the first randomized controlled trial of a manualized psychoanalytical treatment as a sole intervention for panic disorder. This article will describe this treatment and PFPP research studies.

PFPP is based on core psychoanalytical concepts, including the existence and centrality of the unconscious, the relation of defense mechanisms and conflicted wishes to symptom formation, differences between signal and traumatic anxiety, and the importance of transference phenomena. We will discuss these concepts specifically as they relate to the psychodynamic treatment of panic disorder.

From a psychodynamic perspective, symptoms develop in part from unconscious fantasies and conflicts.²⁰ For example, patients with panic disorder often struggle with angry feelings and fantasies, which they experience as threats to important attachment figures.^17,21,22 Although patients are usually aware of some angry feelings, which they commonly find uncomfortable, other unconscious angry or vengeful fantasies that are less tolerable emerge in the course of treatment.

Feelings and fantasies that are experienced as threatening or dangerous are often avoided by unconscious mental processes called defense mechanisms.²³ Certain defense mechanisms are used more frequently by patients with panic disorders. These are reaction formation, undoing, and denial.²⁴ These mechanisms permit the patient to avert recognition of angry feelings toward important love objects and intensify affiliative efforts, with the aim of reducing threats to attachments.

Many aspects of people's lives, including fantasies, behavior, and symptoms, come about as the result of compromise formations, which are a com- promise between a conflicted wish, often unconscious, and the defense against that wish (also unconscious).²⁰ Panic attacks can represent a compromise between angry and dependent wishes that are expressed through a coercive demand for help and a presentation of helplessness to avoid having to acknowledge rage.

As described by Freud, signal anxiety is a small dose of anxiety that alerts the ego to the presence of wishes and impulses that are felt to be dan-gerous, typically triggering defense mechanisms.²⁵ The failure of defenses to modulate the threat leads to traumatic levels of anxiety, akin to what we call panic attacks. In PFPP, therapists work to help patients recognize and reappraise frightening wishes and fantasies.

In the course of psychotherapy, unconscious conflicts and expectations that the patient has developed with others in the past emerge in the relationship with the therapist (transferance).²⁶ A focus on transference during the course of therapy facilitates articulation of overarching fantasies, permitting the patient to gain more understanding and control of them.

A psychodynamic formulation for panic disorder was developed for the purpose of identifying core conflicts to be addressed in a panic-focused psychodynamic treatment. The construction of this formulation from psychoanalytic theory and concepts, including those described above, clinical observations, and more systematic psychological studies, is described in detail elsewhere.^17,21,27,28

The formulation suggests that individuals prone to panic have a fearful dependency on significant others, which is derived from a biochemical vulnerability or traumatic and/or ambivalent relationships with early caregivers that broadly affects their psychological functioning.²⁹ They have a sense of personal inadequacy, and their attachments feel insecure. They often feel they must depend on others to provide a sense of safety, leading separation to be experienced as traumatic. Many patients with panic disorder dread becoming angry at people they love and are frightened that this anger will damage these relationships. A vicious circle of fearful dependency, anger, and anxiety can develop, often triggered by stressors, such as interpersonal loss (Figure 1).³⁰

Based in part on this formulation, the authors developed a manualized treatment, PFPP.¹⁷ In the PFPP research studies, the treatment consists of 24 twice-weekly sessions. This manualized approach targets core conflicts about anger recognition, ambivalent feelings about autonomy, and fears

of loss or abandonment commonly found in panic disorder. Characteristic psychodynamic techniques of clarification, confrontation, and interpretation are used to elucidate and address these conflicts.

The treatment is divided into 3 phases (Figure 2). In the initial phase, the therapist focuses on identifying the meaning and content of panic symptoms, derived from exploring the circumstances, stressors, and feelings surrounding panic onset. Elucidation of a developmental history, including previous panic episodes, helps determine early life experiences and self and object representations that may play an active part in panic. The initial phase aims at relief of panic symptoms.

In the second phase, the therapist works with the patient to identify core conflicts underlying panic disorder. Conflicts surrounding anger and autonomy, as well as other contributing dynamics, are brought to the patient's attention. Defense mechanisms, including reaction formation, undoing, and denial, are addressed as efforts—often unconscious—to avoid facing emotional contributions to panic symptoms. Emergence of the transference allows for exploration of these conflicts and defenses in the relationship between therapist and patient. This phase focuses on addressing vulnerability to panic and relapse.

In the third (termination) phase, mixed feelings surrounding anger, autonomy, and separation are addressed as they emerge in ending the therapeutic relationship. The therapist helps the patient articulate feelings about the loss of the therapist, allowing for further recognition of conflicts and a reduced risk of panic recurrence. Increased assertiveness, encouraged by this patient-directed approach, and an increased sense of safety in being more able to tolerate mixed feelings, helps improve psychosocial function.

Although indications for psychodynamic psychotherapy have been described as good verbal skills, psychological mindedness, and a curiosity about the origins of symptoms, panic patients tend to focus on bodily experiences as a way of avoiding frightening feelings and the verbal articulation of conflict. In studies of PFPP, patients have generally responded well despite often limited psychological mindedness.³¹ Patients become engaged in the treatment as the therapist identifies links between feelings and circumstances surrounding panic onset and patients' emotional lives.

PFPP was initially studied in an open trial of 21 patients with primary DSM- IV panic disorder,^32,33 diagnosed on the Anxiety Disorders Interview Schedule for DSM-IV, Lifetime Version (ADIS-IV-L).³⁴

Four patients dropped out of the study. At the end of treatment, 16 of the remaining 17 patients met remission criteria established by the multicenter study of treatments for panic disorder.¹ Patients experienced significant improvements in psychosocial function, depression, and nonpanic anxiety. These improvements were maintained at 6-months follow-up without intervening treatment. Notably, 8 patients who entered the study meeting DSM-IV criteria for comorbid major depression experienced resolution of depression as well as panic.