Commentary on “Integrating the Psychoanalytic and Neurobiological Views of Panic Disorder”

There have been two great revolutions in modern psychiatry. The first was the psychoanalytic and the second was the psychopharmacologic. The psychoanalytic was purely mentalist in its approach. Nevertheless, it followed a very traditional mode of science. You observed phenomena, and then you developed theories so as to explain those phenomena. Freud, in particular, was a very keen observer and a very imaginative theoretician who offered internally consistent explanations for the phenomena he observed. The major scientific deficit was that the vast majority of the theoretical formulations were not refutable and others could not even be put to an independent test. “Validation” seemed to come only from the couch, and this is not scientifically sufficient.

Nevertheless, at around the time of World War I, laboratory work was done on subliminal perception which tended to support the hypothesis that a great deal of active mental functioning went on beneath the level of consciousness. Unfortunately, very little additional independent testing of the hypotheses has occurred since the work on subliminal perception. The danger of the psychoanalytic approach is that it can become shared misunderstandings that cannot be refuted. The fact that patients improve is not sufficient validation of either the theory or the practice.

In recent years, there has been a greater emphasis on psychoanalytic treatment as a process of unlearning and relearning. In this model, the intense, safe relationship permits the individual to become more open to looking at the conditions surrounding earlier adaptations and to offer newer ways of dealing with the problems of living. The authors state that early traumatic experiences are stored in the amygdala and that reactivation through talk therapy can ameliorate the effect of those early memories. This point is elaborated upon later in this review.

The psychopharmacologic revolution has at times emphasized biology in a man