Panic disorder is a prevalent, debilitating illness associated with high utilization of multiple medical services, poor quality of life and a high incidence of suicide. Short-term efficacy of time-limited cognitive-behavioral and medication treatments has been demonstrated in many studies. Evidence for long-term efficacy of these treatments, however, is sparse and less convincing.
(The authors of this article, along with Arnold Cooper, M.D., and Theodore Shapiro, M.D, in their newly published Manual of Panic-Focused Psychodynamic Psychotherapy, describe a manualized, systematic psychodynamic psychotherapeutic approach for treatment of patients with panic disorder -Ed.)
Panic disorder is a prevalent, debilitating illness associated with high utilization of multiple medical services, poor quality of life and a high incidence of suicide.
Short-term efficacy of time-limited cognitive-behavioral and medication treatments has been demonstrated in many studies. Evidence for long-term efficacy of these treatments, however, is sparse and less convincing. The authors (Milrod and Busch 1996) conducted a review of the long-term outcome of treatment studies for panic disorder. Criteria for inclusion in the review were studies published after 1980 (the publication date of DSM-III), follow-up of patients for at least six months after treatment termination and examination of a specific treatment intervention.
We located 31 studies that met these criteria. A variety of methodological problems appeared in the studies, including lack of clarity of diagnosis, lack of clarity in the treatment administered and inadequately tracked nonstudy treatments during the study and follow-up periods, all of which limited the information which could be obtained about long-term outcome.
In our review, we found that only limited evidence exists to support the notion that gains from short-term treatment interventions were maintained in the absence of continued treatment. Patients are often left with continued impaired global functioning and ongoing anxiety symptoms following treatments which initially brought about symptomatic relief. Long-term outcome studies which closely track additional treatments that patients receive are necessary in order to draw more definitive conclusions about differential treatment efficacy for panic disorder.
In addition to questions about long-term efficacy of the existing antipanic treatments that have been studied, many panic patients are unable or unwilling to tolerate medication and have difficulty complying with behavioral treatment. The treatment approaches that have been studied address quality of life and functional impairment in panic patients in a limited way, with primary treatment centered on panic and agoraphobic symptoms (Markowitz and others). Additionally, because panic disorder is prevalent among women of childbearing age, it is imperative to explore potentially effective nonpharmacologic alternatives.
Residual symptoms and vulnerability to relapse may be partly due to treatment strategies that consider panic symptoms distinct from individual patients' personalities. In this view, panic attacks and agoraphobia are connected to particular personality features, and treating the symptoms alone allows more global characterological problems that lead to panic vulnerability.
Psychodynamic treatment of panic disorder has not been systematically tested. From our clinical experience (Milrod and Shear 1991b) and that of many other psychodynamic clinicians (Renik; Stern; Kessler) as well as a literature review of case studies involving psychodynamic treatment of panic disorder (Milrod and Shear 1991a), we believe that psychodynamic treatment can bring symptomatic relief, often as rapidly as psychopharmacologic or cognitive-behavioral interventions.
Moreover, we believe that psychodynamic psychotherapy, with its broad range of inquiry and techniques, is particularly valuable in addressing the multiple psychological factors involved in vulnerability to recurrence of panic. For the clinician, these techniques can be useful alone, or in conjunction with medications or cognitive-behavioral techniques for patients with persistent symptoms or recurrent episodes of panic.
We have found that panic patients have particular psychological factors that predispose to panic onset and its potential recurrence. These factors include personality problems, disturbances in relationships, difficulties with defining and tolerating certain emotional experiences and unconscious conflicts about separation, anger and sexuality. Panic patients have been characterized as having premorbid personality traits of unassertiveness, insecurity and dependency prior to panic onset (Busch and coworkers 1991).
Our group conducted a pilot study to gain further information about the role of predisposing psychological factors in vulnerability to panic, and meaningful life events connected with panic onset (Busch and cohorts 1991; Shear and others). Nine consecutive subjects with DSM-III-R panic disorder who presented to the Payne Whitney Anxiety Disorders Clinic were videotaped during psychodynamic interviews conducted by Shapiro and Cooper, experienced training analysts. An independent psychoanalyst-rater reviewed the videotapes to assess life events preceding panic onset, capacity to tolerate anger, conflicts about sexuality, descriptions of parents and behaviors and attitudes apart from symptoms of panic disorder.
Identifiable, psychologically meaningful stressors preceded onset of panic in 100% of the subjects assessed in this manner. All stressors involved a loss or alteration in the level of expectations placed on patients. Reported loss events involved physical or emotional separations from a significant person in subjects' lives. Changes in expectations usually reflected subjects being asked to assume increased responsibilities in their occupations. Further exploration in the interviews suggested that subjects linked these events to frightening childhood experiences and viewed them as representing threats to important attachment figures. Seven of nine subjects had difficulty acknowledging angry feelings. Every subject described significant problems in interpersonal relationships, and seven of nine reported occupational difficulties.
In addition to the pilot data described above, Busch and colleagues (1995) systematically compared defense mechanisms employed by panic patients to those used by dysthymic patients. They found that patients with panic disorder employed reaction formation and undoing significantly more than dysthymic patients. These defenses help patients to solidify connections with attachment figures at times when these ties are threatened in fantasy by anger.
In the authors' formulation (Busch and colleagues 1991), patients with panic disorder either have a neurophysiological vulnerability to panic, manifested in early life as behavioral inhibition to the unfamiliar, as defined by Kagan and colleagues; and/or experience traumatic developmental events which likewise affect regulation and modulation of intense affects and anxiety. In either scenario, the authors hypothesized, the child becomes angry at what he or she perceives to be rejecting or frightening behavior on the part of parents. The child becomes fearful of loss and terrified that his or her angry fantasies will destroy the parent upon whom the child depends.
A vicious cycle arises in which rage threatens the all-important tie to the parent, increasing the child's fearful dependency. Immaturity or failure of the ego's signal anxiety function leads to the uncontrollable onset of panic levels of anxiety. This cycle is repeated in adulthood, when threats to attachment reawaken these early conflicts.
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.
Busch FN, Cooper AM, Klerman GL, et al. Neurophysiological, cognitive-behavioral and psychoanalytic approaches to panic disorder: toward an integration. Psychoanal Inquiry. 1991;11(3):316-332.
Busch FN, Shear MK, Cooper AM, et al. An empirical study of defense mechanisms in panic disorder. J Nerv Ment Dis. 1995;183(5):299-303.
Craske MG, Brown TA, Barlow DH. Behavioral treatment of panic: a two-year follow-up. Behav Ther. 1991;22(3):289-304.
Kagan J, Reznick JS, Snidman N, et al. Origins of panic disorder. In: Ballenger JC, ed. Neurobiology of Panic Disorder. New York: Wiley-Liss; 1990.
Kessler RJ. Panic disorder and the retreat from meaning. J Clin Psychoanal. 1996;5(4):505-528.
Markowitz JS, Weissman MM, Ouellette R, et al. Quality of life in panic disorder. Arch Gen Psychiatry. 1989;46(11):984-992.
Milrod B. The continued usefulness of psychoanalysis in the treatment armamentarium for panic disorder. J Am Psychoanal Assoc. 1995;43(1):151-162. See comments.
Milrod BL, Busch FN. The long-term outcome of treatments for panic disorder: a review of the literature. J Nerv Ment Dis. 1996;184(12):723-730.
Milrod BL, Busch FN, Cooper AM, Shapiro T. Manual of Panic-Focused Psychodynamic Psychotherapy. Washington: American Psychiatric Press; 1997.
Milrod B, Shear MK. Psychodynamic treatment of panic: three case histories. Hosp Community Psychiatry. 1991a;42(3):311-312.
Milrod B, Shear MK. Dynamic treatment of panic disorder: a review. J Nerv Ment Dis. 1991b;179(12):741-743.
Renik O. The patient's anxiety, the therapist's anxiety, and the therapeutic process. In: Roose SP, Glick RA, eds. Anxiety as Symptom and Signal. Hillsdale, N.J.: Analytic Press; 1995.
Shear MK, Cooper AM, Klerman GL, et al. A psychodynamic model of panic disorder. Am J Psychiatry. 1993;150(6):859-866. See comments.
Stern G. Anxiety and resistance to changes in self-concept. In: Roose SP, Glick RA, eds. Anxiety as Symptom and Signal . Hillsdale, N.J.: Analytic Press; 1995.