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  1. Panic-Focused Psychodynamic Psychotherapy | Psychiatric Times
  2. Download Symptom Focused Dynamic Psychotherapy
  3. When It's Used
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Psychoanalysts have predicted that manualized treatments would constrict psychoanalysts in their therapeutic approach, reducing the effectiveness of the treatment Blatt The limited research available does not support this concern. Vinnars et al. The authors did not find a significant difference in outcome between the two treatment conditions, and both led to reductions in the number of patients who met the criteria for personality disorder diagnoses, and in the severity of personality disorders and psychiatric symptoms.

The manualization of longer-term treatments, including psychoanalysis, is a more daunting task. Despite these concerns, the potential value of pursuing psychoanalytic research has increasingly been recognized Fonagy ; Fonagy, Roth, and Higgitt ; Gabbard, Gunderson, and Fonagy Systematic studies can help determine for whom psychoanalytic treatments work e. Research of this kind can provide essential feedback to clinicians and help them improve outcomes.

Systematic studies have the potential to settle questions about theory and clinical approaches that thus far have been debated only on the basis of authority, guild allegiance, and the exigencies of clinical experience Shedler The studies of Panic-Focused Psychoanalytic Psychotherapy described below provide a demonstration of the value of such research.

The PFPP studies, an open clinical trial and a randomized controlled trial, were conducted from to at Weill Cornell Medical College, using therapists who were Ph.

Although the therapists in the studies reported here were all psychoanalysts, therapists without psychoanalytic training have since learned PFPP, have participated in a subsequent study, and have been able to conduct the treatment well. All study therapists were given a twelve-hour therapist training course that focused on how to conduct PFPP in accord with the treatment manual. Initial cases were closely supervised.

Integrating Psychodynamic Therapy with CBT

Monthly group supervisory meetings were held that included discussion of particular cases, with review of videotapes. All the therapists availed themselves of additional, individual supervision. The open trial was not an efficacy study, as there was no comparison condition, but was designed to determine whether PFPP could be reliably delivered, and to assess its effects on patients with panic disorder. No concurrent treatments were permitted during this clinical trial, and patients who presented on ineffective anti-panic medications i. In addition to a significant reduction in symptoms of panic disorder, the patients demonstrated significant improvement in measures of psychosocial function, anxiety unrelated to panic, and depression.

Notably, comorbid major depression, present in eight of twenty-one patients, remitted with PFPP as well. Clinical improvements were maintained at six-month follow-up, without intervening treatment. Following the open trial, our group proceeded with a randomized controlled trial Milrod et al.

RCTs are the gold standard for assessment of treatment efficacy, as subjects are randomly assigned to treatment and comparison groups, and both groups are treated identically except for the treatment intervention being studied in this case PFPP vs. Observed changes in symptoms after treatment can be reliably attributed to the effect of the studied intervention, rather than to possible population effects.

Pill placebo is not an apt comparison for a psychotherapy, as it would not control for the time and attention patients receive. CBT is not an apt initial comparison therapy because if the treatments were found to be equally effective, it would be difficult to determine whether both treatments were efficacious, or if the population studied was particularly responsive to treatment.

Head-to-head trials of therapies presumed to be equally active, such as CBT and PFPP, require enough subjects to provide the statistical power to distinguish between the two therapies, each with a high response rate. The next step, comparing CBT with PFPP, must either be appropriately powered, or must also include a less active comparison condition to adequately determine the efficacy of the more active treatments.

ART uses progressive muscle relaxation techniques in which attention is focused on particular muscle groups, with tension and relaxation practiced alternately. Home practice is required twice daily. By the sixth week, subjects apply relaxation skills to anxiety situations outside the office setting in a graduated manner. In the efficacy study, treatments were designed to match in number and frequency of sessions and in the degree of therapist experience, making this treatment trial a conservative one, less likely to show differences between treatment conditions.

Nonetheless, a significantly greater reduction in a broad range of panic symptoms was observed after PFPP, compared with ART, as assessed by the Panic Disorder Severity Scale, the primary outcome measure.


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Work on the PFPP manual was preceded by the development of a psychodynamic formulation of panic disorder Busch et al. The formulation incorporated the work of psychoanalytic theorists and clinicians e.

Panic-Focused Psychodynamic Psychotherapy | Psychiatric Times

In the interviews, patients reported meaningful stressors preceding panic onset that were typically linked to childhood experiences and represented a threat to important attachments. They described their parents as variously temperamental, critical, frightening, demanding, and controlling, and they reported difficulty acknowledging and expressing angry feelings. Based on these clinical observations and studies, a formulation was developed that outlines a series of dynamics central to panic disorder Milrod et al.

In developing the manual, a central goal was to maintain the essential features of a psychoanalytic treatment free association, elucidating unconscious meanings and conflict, developmental exploration, interpretation, use of the transference with adequate flexibility, while focusing on the specific underlying meanings of symptoms of panic disorder.

For this purpose, cases were reviewed to delineate clinical approaches that the authors used in their own psychoanalytic treatment of panic disorder patients. An open-ended exploratory effort to unravel the unconscious, symbolic meanings of panic symptoms and unconscious conflicted fantasies was emphasized. Throughout the text, case vignettes with specific descriptions of therapy dialogue were employed to illustrate the treatment. The use of undoing presents an opportunity for therapists to point out to patients how negative affects often must be disavowed immediately.

K … frequently used the defense mechanism of undoing. Patient: I got to where I really hated my husband—and believe me, I really love him.

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Therapist: I notice that whenever you describe your anger at your husband, you then say how much you love him. The authors identified approximate phases in the treatments that were used to structure the manual. Phase 2 involves determination of specific dynamics underlying panic, which includes aspects of exploration of the transference.

Phase 3 consists of a careful focus on response and reactions to termination. The manual allows for pursuit of a broad range of individual dynamics, including but not limited to the dynamics summarized in the general formulation above. It illustrates how individual sets of dynamics and defense mechanisms can contribute to the onset and continuation of panic disorder, and contains descriptions of psychodynamic techniques and approaches to these dynamics. The manual describes how these dynamics and defenses emerge in the transference and how the transference can be employed in the treatment of panic patients.

After the first draft of the manual was formulated, it was given to four psychoanalysts, all experts in treating anxiety, who had not been involved in its creation, for comment in an effort to ensure that the manual captured the way psychoanalysts in fact treat patients with panic disorder. All four felt the manual closely approximated their own psychoanalytic clinical work, suggesting that operationalizing these approaches need not create a rigid or nonpsychoanalytic treatment.

Adherence rating instruments are essential tools in contemporary psychotherapy outcome research Gerber et al. They provide concrete demonstration that treating clinicians are actually delivering the treatment being studied. In the absence of a well-operationalized adherence rating protocol, therapists may inadvertently be conducting a treatment different from the one being studied, ultimately confusing outcome results.

Critics of psychoanalytic research have cast doubt on the possibility of operationalizing psychoanalytic interventions in a way that allows adherence to be measured see Green Successful adherence rating entails the development of a simple, operationalized description of psychoanalytic psychotherapy, the use of which allows independent raters to obtain similar results when rating the same session see below.


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To accomplish this, specific essential components of the therapy must be clearly articulated. On the PFPP adherence scale, it was necessary to have items differentiating psychoanalytic psychotherapeutic approaches from other psychotherapies. In nonpsychoanalytically based psychotherapies, therapists have preset agendas that determine the content of the session.

It was also necessary to differentiate PFPP from open-ended, non-panicfocused psychoanalytic psychotherapy. Thus, one of the features captured by the PFPP adherence scale is that when the patient pursues topics other than anxiety and panic, the therapist brings the patient back to panic disorder and its associated dynamics. Based on our clinical experience, we consider this focus on panic symptoms to be a crucial component of what makes PFPP effective, though this has not been systematically assessed.

Another item is designed to assess whether the dynamics central to panic disorder are addressed by the therapist. The ICC is a measure of the degree of agreement among raters. Most of the study therapists have easily met adherence standards Milrod et al. The psychoanalytic therapists in our study initially expressed concern over whether use of a manual would limit their flexibility and whether they could meet adherence standards Busch et al. However, once they were engaged in study therapies, their clinical impression was that neither manualization nor adherence standards were disruptive of the psychoanalytic psychotherapeutic process.

These therapists had also expressed discomfort about the need to focus on panic symptoms and dynamics throughout the treatment, but grew increasingly impressed with the therapeutic power of this approach. Their concern about meeting adherence standards eased as their treatments were found in fact to have a high degree of adherence. Despite their initial concerns, the therapists regarded their participation in the study in a positive light. Videotapes provided a valuable tool for group supervisory meetings. The demonstration of efficacy of a psychoanalytic psychotherapy for a DSM-IV Axis I disorder in a scientifically credible randomized controlled trial, along with the effective use of a manual and adherence ratings, has major implications for psychoanalysis and psychiatry.

Opponents of psychoanalytic research must recognize that psychoanalytic treatments can be subjected to rigorous outcome research, just like other psychiatric treatments, while adherents of evidence-based medicine must recognize that psychoanalytic treatment is efficacious with panic disorder. Further studies should be conducted to determine which problems are amenable to psychoanalytic treatments, and what factors make these treatments effective for whom. In addition, comparisons with other psychiatric treatments, including cost-benefit analyses, will be essential. The PFPP efficacy study provides guidance on some clinical debates among psychoanalysts that is more compelling than clinical opinion or individual experience.

For example, many analysts believe that brief treatments are less likely to be effective, because there is limited opportunity for working through conflicts or interpreting transference Malan Few analysts, however, have studied time-limited psychotherapies. Our study found that a course of twenty-four sessions of PFPP was effective in treating panic disorder and improving psychosocial function. In the course of their PFPP therapies, patients addressed intensely negative affect states within and without the transference, as well as conflicted feelings and fantasies.

Our clinical impression is that time-limited psychoanalytic psychotherapy may have intensified the transference, potentially leading to more rapid symptomatic gains. Although brief psychotherapy limits the exploration of conflicts, this does not detract from the utility of this approach for these patients.

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Maintenance of treatment gains, as demonstrated by follow-up data after six months without treatment—see the PFPP open clinical trial Milrod et al. Psychoanalytic clinical lore also argues against the utility of manualized and symptom-focused treatments, as they might disrupt the free-associative process, a technical mainstay of psychoanalytic therapy.

Yet in our studies, symptom focus may have contributed to panic relief, though this was not specifically evaluated. The manualized approach allowed therapists to explore various aspects of the dynamic underpinnings of panic attacks, to develop an increasingly clear formulation of the dynamics, and to share this with the patient in a much more focused manner than they would have in a non-symptom-focused therapy.

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Free association and the monitoring of associations remained central treatment tools. Ultimately, many aspects of free associations were usefully and meaningfully connected to symptoms of panic disorder, as well as to superficially less related conflicts and symptoms. To assess whether symptom focus is important to outcome, however, a systematic study would be required, comparing non-symptom-focused psychodynamic psychotherapy with PFPP.

Some psychoanalysts argue that the demonstration of efficacy for psychodynamic psychotherapeutic treatments adds to the scientific legitimacy of related techniques and to the practice of psychoanalysis Busch ; Kernberg Others Rutherford et al. Thus, research efforts should eventually be directed toward determining the indications and relative utility of both the psychodynamic psychotherapies and psychoanalysis. An understanding of the appropriate place of manualized treatments and efficacy trials, as utilized in the PFPP studies, other psychoanalytic efficacy studies of DSM-IV disorders Clarkin et al.

Possibilities might include 1 further development and testing of manualized treatments of psychoanalytic therapies and psychoanalysis for clearly defined psychiatric syndromes and disorders and 2 comparison of manualized psychoanalytic treatments with other psychotherapeutic treatments, as well as psychopharmacological approaches.