Panic-focused psychodynamic psychotherapy (PFPP) differs from more traditional psychodynamic psychotherapies in its sustained focus on panic and agoraphobic symptoms and the associated dynamics described above. PFPP can be roughly divided into three phases aimed at relief of panic symptoms and reducing vulnerability to panic relapse and functional impairment.
In the first phase of the treatment, the goal of interventions is to explore and relieve panic symptoms. The therapist explores the stressors and feelings surrounding panic onset, the conscious and unconscious meanings of panic symptoms and the emotional and fantasy content of panic episodes. As this exploration proceeds, the therapist is able to formulate unconscious dynamisms connected to the genesis of the patient's panic episodes, including conflicts about separation and independence, anger recognition and management and some sexual conflicts.
In the second phase of treatment, the goal is reduction of panic vulnerability through further exploration of core conflicts and dynamisms associated with panic. During this phase, intensification of the transference allows for increasing work on these conflicts as they relate to the therapist. As the patient's unconscious conflicts emerge in therapy, they are linked with the origins and content of panic episodes. Successful working-through leads to characterological changes such as increased assertiveness, and a less conflicted and anxious experience of separation, anger and sexuality.
In Phase III, the termination phase, panic patients' difficulties with separation and anger are addressed directly in the relationship with the therapist as they are experienced in the context of terminating the treatment. Here, they can be examined, articulated and understood in a way that makes them less frightening. Reexperiencing these feelings can lead, in some cases, to a temporary return of symptoms. Nonetheless, the outcome of this phase of treatment is a new ability to acknowledge and tolerate affects in the context of separation and loss.
PFPP can be used in conjunction with cognitive-behavioral treatments or medication. PFPP can aid in understanding and grappling with patients' resistances to cognitive-behavioral treatment and to medication. Likewise, cognitive-behavioral treatment and medication can facilitate anxiety reduction, permitting patients to become more engaged in psychodynamic exploration. The Manual of Panic-Focused Psychodynamic Psychotherapy provides an extended example of a treatment that combined PFPP with a cognitive-behavioral approach.
Indeed, certain approaches that have come to be labeled as cognitive-behavioral have always been incorporated into psychodynamic psychotherapy. Clarification of a patient's situation in reality falls into this category. In contrast to cognitive-behavioral practice, however, the PFPP therapist goes on to explore the meaning and unconscious significance of the patient's panic experiences and fantasies after the patient is reassured that the frightening physical sensations are not signs of serious underlying illness. Rich and significant clinical material emerges with this approach. For example, in association to her own shortness of breath during panic attacks, one patient began to describe the pain and terror she experienced while viewing her mother's shortness of breath when her mother was dying. For that patient, it became clear during the preliminary psychodynamic exploration of her symptoms that her panic experience was somehow connected to her complicated emotional reaction to her mother's death.
Ultimately, it will be important to determine which of the variety of available treatment interventions for which selected groups of panic patients are of greatest value in relieving panic and agoraphobia in the short and long term. To that end, the authors are undertaking a systematic study of PFPP.