Panic-Focused Psychodynamic Psychotherapy
By Fredric N. Busch, MD and Barbara L. Milrod, MD |
February 1, 2008
Dr Busch is clinical associate professor of psychiatry and Dr Milrod is professor of psychiatry at Weill Medical College of Cornell University in New York City. They report no conflicts of interest concerning the subject matter of this article.
Our group recently completed a landmark study in which we demonstrated efficacy of PFPP for panic disorder with and without agoraphobia.18 This was a randomized controlled trial comparing PFPP to a less-active psychotherapy, ART.19 Inclusion criteria were a diagnosis of primary DSM-IV panic disorder with or without agoraphobia (ADIS-IV-L), with at least 1 panic attack per week. Patients entering the study agreed to stop all nonstudy psychotherapy and to hold their medication constant if they were taking medication (15% of the sample). Patients with comorbid severe agoraphobia, major depression, and DSM-IV personality disorders were included. Exclusion criteria were psychosis, bipolar disorder, and substance abuse (6-months remission necessary).
The Panic Disorder Severity Scale (PDSS) was the primary outcome measure.35 Response was defined as a 40% reduction from baseline on the PDSS.1 Patients were assessed with the Sheehan Disability Scale (SDS),36 the Hamilton Rating Scale for Anxiety (HAM-A),37 and the Hamilton Rating Scale for Depression (HAM-D).38 Both therapies were of 12 weeks' duration, with twice-weekly (24 session) interventions. ART included a cognitive explanation about panic disorder, progressive muscle relaxation, cue-controlled relaxation, twice-daily homework, and an exposure protocol.
Psychotherapy sessions were videotaped for adherence monitoring. Both groups demonstrated high levels of adherence to the manualized treatments based on an assessment of 3 videotapes of each therapy using condition-specific adherence measures: the PFPP Adherence Rating Scale (available from the authors) and the ART Adherence Scale.39
No significant demographic or clinical differences were found between the 2 treatment groups at baseline besides sex—more men were in the ART group: 47% versus 15%; 2-tailed Fisher's exact P < .05 (Table 1). There were no baseline differences between randomized groups in severity of panic disorder, PDSS score, or baseline severity ratings. PFPP had a significantly higher response rate than ART: 73% versus 39%; P = .016 (Table 2); and significantly greater improvement in symptoms of panic disorder: PDSS, P = .002 (Figure 3) and psychosocial function: SDS, P = .014. The 2 treatments did not differ significantly in changes on the HAM-D (P = .07) or in nonpanic anxiety (HAM-A, P = .58).
Only 2 patients in the PFPP group dropped out (7%), an unusually low attrition rate for a randomized controlled trial of panic disorder in the United States, compared with 8 dropouts in the ART group (34%). Patients had good response to treatment despite the inclusion of severe agoraphobia and comorbid depression, making this sample relatively more generalizable than subjects in some other panic disorder outcome studies.1,2,7,40,41 PFPP performed comparably to clinical trials of cognitive-behavioral therapy (CBT) and medication, but these treatments were not directly compared with one another. Currently, a 2-site study (Cornell, New York and University of Pennsylvania, Philadelphia) is under way comparing PFPP with CBT and ART.
Preliminary moderator analyses of the efficacy study showed that patients with primary DSM-IV panic disorder with comorbid SCID-II-diagnosed Axis II cluster C disorders responded better to PFPP than patients without this comorbidity.42 Because panic patients with cluster C comorbidity have not always responded well to CBT,43 PFPP may be of particular value for this population.
Although the results of the PFPP studies are promising, further studies are needed to determine which treatment interventions are most appropriate for any given patient with panic disorder.
Mr B had onset of severe panic disorder 2 days after his 39th birthday and presented with a score of 12 on the PDSS. In the first phase of treatment, the therapist explored the circumstances surrounding panic onset. Although Mr B acknowledged that he had been "stressed," he was puzzled about the source of the panic attacks. He focused initially on problems at work: he was not comfortable with the pressure at work since being promoted to leader of his division. As therapy progressed, he started to realize that he had been having some of the symptoms of his subsequent panic attacks for several weeks before their onset when having to reprimand or fire employees. Specifically, he felt tremors in his arms and a sense of loss of control.
Mr B described a difficult background. His father was a temperamental man who was especially intolerant of his son's early reading and writing difficulties. He described his mother as self-absorbed, often neglecting him. On 3 occasions, his parents sent him away from home, once to relatives and twice to boarding schools, for reasons he did not understand at the time. As a child, he assumed he was sent away because he was "bad," or he was being punished for losing his temper with his mother. His parents often fought and ultimately divorced.
Although his relationship with his father improved over the years, his mother became a lonely embittered woman who viewed herself as a victim of unfair life circumstances. She pressured Mr B to take care of her, which he experienced as efforts to draw him away from his wife and job. Although he was angry at his mother's refusal to make efforts to take better care of herself, he felt guilty saying no to her.
Mr B's panic attacks resolved within the first 6 sessions of PFPP, as he began to recognize that his panic arose as a result of intense fears about confronting his employees that were related to his early separation experiences.
In phase 2, his difficulty in tolerating his anger and his fears of abandonment were explored in more depth. It emerged that Mr B felt frightened about reprimanding his employees, because even though he was the boss, he feared that he would be abandoned or punished, just as he felt would happen if he confronted his mother about her selfish behavior. Mr B's panic attacks were also triggered by his rage at his employees, particularly one whose victimized stance reminded him of his mother. Unconsciously, he feared both loss of control of his anger (Mr B's shaking arms during his anxiety and panic) and being abandoned and punished for its expression, which he linked to his being sent away as a child. He had avoided his anger heretofore with reaction formation, taking greater care of his mother while fending off his rage.
In the final phase of treatment, Mr B discussed his frustration and abandonment fears as they emerged in the transference with the therapist. He expressed a concern that the therapist would not be able to tolerate his feelings about leaving the treatment and would become angry with him. Recognizing this transference fear as a fantasy deepened his understanding of the conflicts that had been identified earlier in the treatment. As his fears subsided, Mr B became more effective in his functioning as a boss, and was able to set better limits with his mother. On completion of his 24-session treatment, he had a score of 1 on the PDSS.
- Barlow DH, Gorman JM, Shear MK,Woods SW. Cognitive- behavioral therapy, imipramine, or their combination for panic disorder. JAMA. 2000;283:2529- 2536.
- Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007;164:265- 272.
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