With the support of a grant from the Fund for Psychoanalytic Research of the American Psychoanalytic Association, we and our colleagues are conducting a research study of a form of psychodynamic psychotherapy for panic disorder for which we have created a manual.
Although many case reports suggest that psychodynamic treatment can relieve panic symptoms, there are no controlled studies documenting psychodynamic psychotherapy as a reliever of panic disorder. In contrast, both cognitive-behavioral and psychopharmacological treatments have proven successful in treating panic patients.
In the current health care climate, if we do not study psychodynamic psychotherapeutic approaches systematically for specific disorders, these treatments will not take their proper place in accepted treatment guidelines for psychiatric disorders, in psychiatric education, or in reimbursement systems. For example, the final draft of therapeutic guidelines for treatment of panic disorder circulated by the American Psychiatric Association contains minimal references to psychodynamic psychotherapy as a viable treatment for panic disorder.
Further assessment of various treatments for panic disorder is essential. The efficacy of current treatments over the long term is far from clear. The literature shows that when short-term treatment interventions have been assessed for long-term outcome, patients suffer high relapse rates and continued impaired global function. Many panic patients continue to have persistent, ongoing anxiety symptoms even after treatments that initially brought about symptomatic relief. Patients frequently require continued treatment. This is significant because panic disorder is an important public health problem, associated with high rates of use of medical and psychiatric services.
The persistence or recurrence of panic symptoms after short-term treatment interventions will not surprise psychoanalysts. Studied treatments have traditionally focused on panic disorder and agoraphobic symptoms; researchers have been less concerned with the related psychological and psychosocial difficulties commonly found in panic patients.
Patients with certain personality traits may be more vulnerable to recurring panic and persistent symptoms. Many observers and some systematic studies suggest that these traits include unassertiveness and dependency, as well as difficulties with acknowledging feelings of anger and loss prior to panic onset. We hypothesize that psychodynamic psychotherapy can best address the multiple psychological factors that are involved in panic vulnerability.
In order to systematically assess the impact of psychodynamic treatment on panic disorder symptoms, it was necessary to develop a treatment manual that would set forth a distinct and reproducible intervention. Along with Arnold Cooper and Theodore Shapiro, we wrote the Manual of Panic-Focused Psychodynamic Psychotherapy (1997) in part for this purpose. Panic-focused psychodynamic psychotherapy (PFPP) differs from more traditional psychodynamic psychotherapies in its focus on panic and agoraphobia and the conflicts associated with this disorder.
Our treatment approach was derived from psychological studies of panic patients and clinical data generated from these studies. In a series of psychodynamic interviews with nine patients suffering from panic disorder, we found that all the patients described psychologically meaningful stressors that preceded the onset of their panic attacks. These events included perceived or actual separations from important people in their lives or events that led to an increase in responsibilities.
When these matters were explored further, we found that the patients connected these events to frightening childhood experiences and viewed them as threats to important attachment figures. The patients described their parents as temperamental, overprotective, controlling, or critical. Seven of the nine patients reported difficulties with acknowledging and expressing angry feelings. All of the patients described difficulties in their relationships, and seven of the nine had difficulty functioning at their jobs.
In another study, we systematically assessed defense mechanisms in these patients. Compared to a group of chronically depressed patients, panic patients tended to employ reaction formation and undoing to a greater degree than do patients with dysthymic disorder. We hypothesized that due to underlying instability experienced in relation to important attachment figures, panickers tend to employ defense mechanisms that minimize or deny their anger and heighten their affiliative efforts.
When the data were organized into a psychodynamic formulation, they suggested that people who are vulnerable to panic often have a neurophysiological vulnerability that leads them to fear unfamiliar situations when young. This fear in turn may cause them to depend more on their parents for protection. In addition, patients may have frightening experiences with caretakers in their early lives that contribute to these fears. Because they feel unable to manage their environment, they often experience narcissistic injury and tend to blame their difficulties on their parents, intensifying a view of important love objects as unhelpful, critical, or rejecting. This triggers anger at the parents; however, because of feelings of heightened dependency, panic patients are fearful of acknowledging this anger. They fear that their parents will retaliate by becoming angry or rejecting. A vicious cycle arises in which anger threatens the important tie to the parent, increasing patients' fears, in turn further increasing the sense of dependency and anger. When threatening events occur in adulthood, this cycle is triggered and anxiety can intensify to the level of panic.
Recently, our work group has been modifying the above formulation to address the contribution of Oedipal-level factors to panic onset. Frequently, feelings of inadequacy, which can become associated with homosexual longings and anxieties, trigger a defensive aggressive Oedipal stance to compensate for these feelings (counterphobic defenses). However, aggressive feelings create anxiety due to fears of abandonment, as outlined above. This can lead to a regressive, helpless defensive pattern to protect against dangerous Oedipal strivings. This pattern of helplessness, aggressive response, and regression adds to the vicious cycle of intensifying anxiety described above.
PFPP was designed to function (1) as a short-term treatment to give immediate relief of panic symptoms and (2) as a longer-term treatment designed to address further personality changes. The therapist begins by exploring the stressors and feelings that the patient reports at the time of panic onset, the meanings of panic symptoms, and the specific fantasies and feelings that make up panic episodes. The therapist is then able to formulate how various thoughts and
Fredric N. Busch, M.D., and Barbara L. Milrod, M.D., are assistant professor of psychiatry and assistant clinical professor of psychiatry, respectively, at Cornell University Medical College. Busch is on the faculty of Columbia University Center for Psychoanalytic Training and Research. Milrod is a graduate of the New York Psychoanalytic Institute.
feelings contribute to panic, such as the fears of anger and separation described above. As the therapeutic relationship deepens, the therapist explores the emergence of these conflicted feelings in the transference. As termination approaches, these issues are explored as they relate to separation from the therapist.
In order to undertake this study, we have trained four additional psychoanalysts in the administration of PFPP: Jean Roiphe, Marie Rudden, Andrew Aronson, and Meriamne Singer. We developed an adherence scale designed to systematically evaluate whether the treatment the therapists are delivering in the study is consistent with PFPP as described in the manual.
The study treatment consists of 24 videotaped sessions over a 12-week period. Treatment is free of charge. Twenty-eight patients completing the course of treatment will be sought for the current open clinical trial. Subjects are systematically assessed for panic and associated symptoms before treatment, immediately post-treatment, and at six months after treatment is terminated.
The therapists in this study are psychoanalysts unaccustomed to performing short-term treatments with set termination dates. They have described the treatments thus far as intensive, with large amounts of material covered in a relatively brief period.
Patient recruitment for this study is essential. We hope that psychoanalysts in various settings will consider sending referrals for this study. Interested patients should call Barbara Milrod at 212-746-5868.