Neurophysiological, cognitive‐behavioral, and psychoanalytic approaches to panic disorder: Toward an integration

Assessing the potential of ChatGPT for psychodynamic formulations in psychiatry: An exploratory study

Although there were several attempts to apply ChatGPT (Generative Pre-Trained Transformer) to medicine, little is known about therapeutic applications in psychiatry. In this exploratory study, we aimed to evaluate the characteristics and appropriateness of the psychodynamic formulations created by ChatGPT. Along with a case selected from the psychoanalytic literature, input prompts were designed to include different levels of background knowledge. These included naïve prompts, keywords created by ChatGPT, keywords created by psychiatrists, and psychodynamic concepts from the literature. The psychodynamic formulations generated from the different prompts were evaluated by five psychiatrists from different institutions. We next conducted further tests in which instructions on the use of different psychodynamic models were added to the input prompts. The models used were ego psychology, self-psychology, and object relations. The results from naïve prompts and psychodynamic concepts were rated as appropriate by most raters. The psychodynamic concept prompt output was rated the highest. Interrater agreement was statistically significant. The results from the tests using instructions in different psychoanalytic theories were also rated as appropriate by most raters. They included key elements of the psychodynamic formulation and suggested interpretations similar to the literature. These findings suggest potential of ChatGPT for use in psychiatry.

Problem-Focused Psychodynamic Psychotherapies

Psychoanalytic approaches, although still extensively used by practitioners, have been marginalized in treatment guidelines partly because of limited efficacy research. In recent years, several manualized psychodynamic approaches have been developed that target specific problems or disorders, which can be referred to generally as problem-focused psychodynamic psychotherapies. These treatments offer modified psychodynamic techniques to address dynamics associated with particular disorders and can be used for systematic outcome studies. For example, one of these, panic-focused psychodynamic psychotherapy, has demonstrated efficacy in the treatment of panic disorder. The manuals for these psychotherapies emphasize comprehensibility for training purposes and are more readily transportable to the public health sector. Extensive research will be needed to ascertain which psychotherapies are most effective for various patients and conditions over the short and long term.

A MODEL FOR INTEGRATING ACTUAL NEUROTIC OR UNREPRESENTED STATES AND SYMBOLIZED ASPECTS OF INTRAPSYCHIC CONFLICT

In psychoanalytic theory, the importance of actual neuroses-considered to be devoid of psychic content-diminished as Freud and subsequent analysts focused on unconscious intrapsychic conflict. This paper explores the relationship between actual neurotic and unrepresented states, which are believed to be best addressed through attention to countertransference, intersubjectivity, and enactments rather than interpretation of intrapsychic conflict. Models suggesting how actual neurotic states and symbolized intrapsychic conflict may interact with each other and environmental stressors are described. Symbolizing actual neurotic states and establishing meaningful linkages between somatic/affective experiences and intrapsychic conflict are viewed as necessary for effective treatment of many disorders.

Psychodynamic Treatment for Separation Anxiety in a Treatment Nonresponder

Separation anxiety, long an area of interest for psychoanalysts, has been included in DSM-5 among general "anxiety disorders" that span across age groups. The syndrome of separation anxiety has been shown to correlate with nonresponse to treatments for anxiety and mood disorders (Milrod et al. 2014). It is therefore of public health importance to develop targeted treatments for this syndrome. Some psychoanalysts have suggested that brief psychoanalytic interventions may be of particular value in addressing separation anxiety. Our clinical work with patients with anxiety disorders with high levels of separation anxiety indicates that they have such intense anger and ambivalence in fraught intimate relationships that they feel stuck and helpless, almost eliminating more positive feelings. This ambivalence and associated unconscious conflicts inevitably emerge in the therapeutic relationship and can threaten to disrupt treatment efforts. We propose a set of focused psychodynamic psychotherapeutic interventions to address separation anxiety, developed as part of Panic-Focused Psychodynamic Psychotherapy-eXtended Range (PFPP-XR; Busch et al. 2012). We present a case from our research study of treatment nonresponders with anxiety disorders and separation anxiety. The patient was successfully treated with PFPP-XR in a 21-session treatment.

Unmentalized aspects of panic and anxiety disorders

Somatic or emotional experience that has not been symbolically represented, referred to as unmentalized experience, has been given an increasingly prominent role in understanding psychopathology. Panic and anxiety disorders provide a useful model for exploring these factors, as the affective and bodily symptoms can be understood in part as unmentalized experience. The authors explore models of Freud's actual neurosis, Marty and DeM'uzan's pensee operatoire, Klein's unconscious fantasy, Bion's alpha function, Bucci's multiple code system, and relational models to describe how somatic and affective experiences can be translated into symbolic representations, and what factors can interfere with these processes. Approaches to unmentalized aspects of panic and anxiety include symbolizing somatic symptoms, identifying emotional states, and identifying contextual and traumatic links to symptoms.

Clinical approaches to somatization

Somatization is the experience and expression of psychological distress through bodily symptoms. Somatization can be conceptualized as an emotional state that has not been represented symbolically or as a defense against intolerable emotions and fantasies. Bodily concerns can also function as a means of seeking responsiveness from others. Alexithymia refers to a difficulty identifying and symbolizing emotional states that has been found to be associated with somatization. When functioning as a defense, a focus on the body can be used to avoid frightening or intolerable feelings and fantasies, or to ward off aggressive fantasies by viewing oneself as physically damaged. Systematic studies have demonstrated the presence of the defense of somatization in mood disorders, particularly anxiety and panic disorders. In treating anxiety disorders, the therapist helps the patient to determine the nature of emotions and fantasies that the patient is defending against, particularly fears and conflicts surrounding anger and separation.

Mental representations in women with panic disorder: an urban African-American sample

Psychodynamic theories of panic disorder (PD) suggest an association between PD and impairments in mental representations. This study tested this hypothesis by comparing mental representations of 25 African-American women recruited from an urban primary care clinic with PD with a group of 25 women without PD and matched on race, age, marital status, education, and income. Mental representations were assessed through spontaneous descriptions of mothers and reliably coded with the Qualitative and Structural Dimensions of Object Representations scale (Blatt et al., Unpublished manual, 1992). Results essentially supported the hypotheses for impaired mental representations (lower benevolence, higher ambivalence, and lower conceptual level) for women with PD as compared with women without PD. No differences in mental representations were found between women with PD with major depression and women with only PD. The findings provide preliminary support for a psychodynamic theory of PD in a sample of African-American women.

Differentiation of depression and anxiety groups using defense mechanisms

We examined whether participants in depressed and anxious groups could be classified correctly using observer and self-report measures of defense mechanisms. A sample of 1182 university students completed the Personality Assessment Inventory and those scoring in the clinical range on either depression or anxiety indices were selected for participation. In total, 25 participants met criteria for the depressed group and 94 met criteria for the anxious group. Individual defense scores from the Defense-Q and the Defense Style Questionnaire were separately entered into 2 stepwise discriminant analyses. After cross-validation, the Defense-Q and Defense Style Questionnaire analyses classified participants with 75.0% and 71.3% accuracy, respectively. The results indicated that depression and anxiety groups can be significantly differentiated by defense use alone. Important differences in defensive functioning between these groups were confirmed and differences between observer and self-report measures of defenses mechanisms and current challenges in defense research were highlighted.

A study demonstrating efficacy of a psychoanalytic psychotherapy for panic disorder: implications for psychoanalytic research, theory, and practice

Systematic research on psychoanalytic treatments has been limited by several factors, including a belief that clinical experience can demonstrate the effectiveness of psychoanalysis, rendering systematic research unnecessary, the view that psychoanalytic research would be difficult or impossible to accomplish, and a concern that research would distort the treatment being delivered. In recent years, however, many psychoanalysts have recognized the necessity of research in order to obtain a more balanced assessment of the role of psychodynamic psychotherapy and psychoanalysis in a contemporary treatment armamentarium, as well as to allow appropriate evaluation and potentially greater acceptance by the broader mental health and medical communities. In this context, studies were conducted of a psychodynamic treatment, Panic-Focused Psychodynamic Psychotherapy (PFPP), initially in an open trial and then in a randomized controlled trial (RCT) in comparison with a less active treatment, Applied Relaxation Training (ART; Cerny et al. 1984), for adults with primary DSM-IV panic disorder. The results of the RCT demonstrated the efficacy of PFPP in treating panic disorder, and also demonstrated that a psychoanalytic treatment can be systematically evaluated in a mode consistent with the principles of evidence-based medicine. Two specific features of the methodology, the development of the treatment manual and the operationalization of the adherence instrument, both core building blocks of contemporary psychotherapy outcome research, and their implications for psychoanalytic research are discussed in greater depth. The theoretical, clinical, and educational implications of the PFPP studies are elaborated, and suggestions are made for pursuing further outcome research of psychoanalytic treatments.

An open pilot study of interpersonal psychotherapy for panic disorder (IPT-PD)

Interpersonal psychotherapy (IPT) is a time-limited psychotherapy initially developed to treat depression. It has yet to be studied systematically for treatment of panic disorder. We modified IPT for the treatment of panic disorder and tested this treatment in an open clinical trial with 12 patients seeking treatment of DSM-IV panic disorder. Patients were assessed before during and after treatment. At completion of treatment, nine patients (75%) were independently categorized as responders (i.e., rated as much improved or very much improved on the Clinical Global Impression-Change Scale). Substantial improvement was found for panic symptoms, associated anxiety and depressive symptoms, and physical and emotional well-being. Degree of change in this sample approximated that obtained in studies using established treatments such as cognitive behavioral therapy. Results, though preliminary, suggest that IPT may have efficacy as a primary treatment of panic disorder. Further study is warranted.

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.

[Is there an approach of psychoanalytical inspiration specifically adapted to anxiety disorders?]

Psychoanalytic treatments have been relegated to a secondary status in the current recommendations concerning the treatment of anxiety disorders. This is due to the lack of controlled studies pertaining to these psychotherapies, as well as to the late adaptation of psychoanalysis to the contemporary trends of psychopathology and psychotherapy focusing on symptoms. The recent development of a manualized psychotherapy for the treatment of panic disorder, the Panic-Focused Psychodynamic Psychotherapy (PFPP), is a good example of such an adaptation (Milrod et al., 1997). PFPP appears to be effective (Milrod, 2001). This type of psychotherapy is probably neither more nor less effective than other forms of psychotherapy if one considers the results of empirical research on the comparative effectiveness of psychotherapies. The question formulated by the title of this paper is perhaps less central as is that of the nature of the active factors of the psychotherapeutic process.

Idiopathic Environmental Intolerance

Toxicogenic and psychogenic theories have been proposed to explain idiopathic environmental intolerance (IEI). Part 2 of this article is an evidence-based causality analysis of the psychogenic theory using an extended version of Bradford Hill's criteria. The psychogenic theory meets all of the criteria directly or indirectly and is characterised by a progressive research programme including double-blind, placebo-controlled provocation challenge studies. We conclude that IEI is a belief characterised by an overvalued idea of toxic attribution of symptoms and disability, fulfilling criteria for a somatoform disorder and a functional somatic syndrome. A neurobiological diathesis similar to anxiety, specifically panic disorder, is a neurobiologically plausible mechanism to explain triggered reactions to ambient doses of environmental agents, real or perceived. In addition, there is a cognitively mediated fear response mechanism characterised by vigilance for perceived exposures and bodily sensations that are subsequently amplified in the process of learned sensitivity. Implications for the assessment and treatment of patients are presented.

The effects of medication on the psychoanalytic process. The case of selective serotonin reuptake inhibitors

This paper deals with two analysands who developed serious symptoms of anxiety and depression during the middle phase of their analysis. The symptoms were severe enough to disrupt the previously established analytic process. After a consultation, both patients were put on a selective serotonin reuptake inhibitor (SSRI). Both responded well to the medication, not only in terms of symptom reduction but also in re-establishing the analytic process. Both patients made very little reference to medication after an initially negative reaction to the suggestion of a psychopharmacology consultation. The process of seeking a consultation, the prescription and monitoring of the medication, the concept of medications as parameters, and the possible reasons for the virtual absence of references to medication are discussed.

How treating psychoanalysts respond to psychotherapy research constraints

The psychoanalytic community increasingly recognizes the importance of research on psychoanalytic treatments, yet a significant number of psychoanalysts continue to believe that research is either irrelevant to psychoanalysis or impossible to accomplish. Psychoanalysts who accept the value of research express concern that intrusions required by research protocols create significant distortions in the psychoanalytic process. The authors, all psychoanalysts, are studying the outcome of a brief (twenty-four-session) psychodynamic treatment of panic disorder. They report their experiences and struggles with the intrusions of videotaping, working with a treatment manual, and time-limited treatment. This research process required them to question old beliefs and to confront feelings of disloyalty toward their analytic training and identity, particularly with regard to keeping a "clean field" and routinely performing long-term analysis of character. The therapists' psychoanalytic knowledge, however, emerged as crucial for them in managing specific research constraints. Despite concerns about providing inadequate treatment, therapists were found to engage patients with psychoanalytic tools and focus in vibrant and productive therapies that led to significant improvements in panic symptoms and associated quality of life. The authors suggest that psychoanalysts have been overestimating the potential damage of research constraints on psychoanalytic process and outcome.

Oedipal dynamics in panic disorder

Both research and clinical work have revealed factors that can lead to the onset and persistence of panic disorder. Preoedipal conflicts intensify the danger of oedipal longings for panic patients. Competition with the same-sex parent is linked with angry preoedipal fantasies and associated fears of disruption in attachments. Fantasies or actual successes can thus trigger panic episodes. Regression to a helpless, dependent state such as panic defends against the danger of aggressive, competitive fantasies and actual achievements. However, the regressive state can also be experienced as dangerous, and can be linked with frightening homosexual fantasies. A reactive aggressive oedipal stance can sometimes result, triggering escalating turmoil. The panic episode serves a series of compromise formations in dealing with these conflicted wishes.

Unconscious pregnancy fantasies as an underlying dynamism in panic disorder

Unconscious pregnancy fantasies are outlined as an underlying dynamic organizer to the panic experience in some patients with panic disorder. Detailed case material from the treatment of two childless panic patients, one male and one female (nonpregnant) is presented to illustrate this. A literature review found reports of nine nonpregnant patients, none exposed to a pregnant analyst, in whom these fantasies are described as central. Four of these patients had a psychiatric syndrome consistent with panic and agoraphobia. Some mechanisms that may underlie these connections are explored.