Affect-Focused and Exposure-Focused Psychotherapies

The authors discuss the two broad domains of affect-focused and exposure-focused psychotherapies, defining the characteristics and potential advantages and disadvantages of each. The two domains differ in their theoretical approaches, structures, and techniques. Exposure-focused therapies have come to dominate research and practice, leading to the relative neglect of affect-focused therapies. When the two approaches have been examined in well-conducted clinical trials, they generally appear to be equally beneficial for treating common mood, anxiety, and trauma disorders, although further research may better define differential therapeutics. The authors argue for better training in affect awareness and tolerance across psychotherapies and use a brief case vignette to illustrate several aspects of these different approaches.

Open Trial of Trauma-Focused Psychodynamic Psychotherapy for Posttraumatic Stress Disorder Among LGBTQ Individuals

OBJECTIVE

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals report higher rates of exposure to traumatic events and posttraumatic stress disorder (PTSD) compared with heterosexual and cisgender individuals. No treatment outcomes research has focused on PTSD in the LGBTQ population. Trauma-focused psychodynamic psychotherapy (TFPP) is a brief, manualized, attachment- and affect-focused psychotherapy for PTSD. TFPP explicitly incorporates broad identity-related and societal factors into its conceptualization of trauma and its consequences, which may be especially helpful for LGBTQ patients with minority stress who seek affirmative care.

METHODS

Fourteen LGBTQ patients with PTSD, assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), received 24 sessions of twice-weekly (12 weeks) TFPP via teletherapy provided by supervised early-career therapists inexperienced in the modality. Sessions were videotaped to monitor therapists' treatment adherence. Patients were assessed at baseline, week 5, termination (week 12), and 3 months posttreatment for PTSD symptoms (assessed with the CAPS-5) and secondary outcomes.

RESULTS

TFPP was well tolerated by patients, with 12 (86%) completing the intervention. CAPS-5-measured PTSD symptoms, including dissociation, significantly improved during treatment (mean decrease=-21.8, d=-1.98), and treatment gains were maintained at follow-up. Most patients experienced PTSD clinical response (N=10, 71%) or diagnostic remission (N=7, 50%). Patients generally experienced significant, concomitant improvements in complex PTSD symptoms, general anxiety, depression, and psychosocial functioning. Adherence to the intervention among therapists was high, with 93% of rated sessions meeting adherence standards.

CONCLUSIONS

TFPP shows promise in the treatment of PTSD among sexual and gender minority patients seeking LGBTQ-affirmative PTSD care.

Postpandemic Psychotherapy: Still Under Siege

The authors review the past and current challenges in psychotherapy training, research, and practice and the state of psychotherapy in the context of current training and funding, the COVID-19 pandemic, and the current era's pursuit of novelty. Where does the field stand, and where should it go?

ENIGMA-anxiety working group: Rationale for and organization of large-scale neuroimaging studies of anxiety disorders

Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA-Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. This paper elaborates on the concepts and methods informing the work of the working group to date, and describes the initial approach of the four subgroups studying generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobia. At present, the ENIGMA-Anxiety database contains information about more than 100 unique samples, from 16 countries and 59 institutes. Future directions include examining additional imaging modalities, integrating imaging and genetic data, and collaborating with other ENIGMA working groups. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA-Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders.

Predictors and moderators of treatment dropout in cognitive-behavioral and psychodynamic therapies for panic disorder

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.

Treatment of anxiety and mood comorbidities in cognitive-behavioral and psychodynamic therapies for panic disorder

BACKGROUND

It is not known whether common anxiety/mood comorbidities of panic disorder (PD) improve with panic-focused psychological treatment, nor whether there is differential efficacy between therapies in treating comorbidities.

METHODS

In a randomized controlled trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), symptomatic comorbidities of agoraphobia, MDD, GAD, and social anxiety disorder (SAD) were assessed pre-to-post treatment with the Anxiety Disorders Interview Schedule (ADIS). Comparative efficacy of CBT versus PFPP for treating comorbid disorders was tested at termination and 1 year's follow-up. Covariance between panic and comorbidity improvements was also analyzed.

RESULTS

Most treatment completers (n = 120) evidenced diagnostic remission of their comorbidity (range = 54-69%), which typically reflected a subclinical score on the ADIS (mean range = 1.3 to 1.8). These improvements were generally retained at follow-up. However, patients with MDD dropped out significantly more often (HR = 2.79). No significant symptom change or remission differences emerged between CBT and PFPP for any comorbidity at termination or at follow-up. Panic change was strongly related to improvements in agoraphobia (r = 0.70) and MDD (r = 0.53), moderately related for GAD (r = 0.31), and not significantly related for SAD (r = 0.20).

DISCUSSION

Patients completing panic-focused psychotherapies often experience meaningful remission for diagnoses of agoraphobia, MDD, GAD, and SAD, with no detectable differences between treatments, although sample sizes for the MDD and SAD comparisons were small. In addition, additional efforts may be needed to keep MDD-comorbid patients in treatment.

In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy

In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trauma-Focused Psychodynamic Psychotherapy

The authors describe a psychodynamic psychotherapeutic approach to posttraumatic stress disorder (PTSD), trauma-focused psychodynamic psychotherapy. This psychotherapy addresses disruptions in narrative coherence and affective dysregulation by exploring the psychological meanings of symptoms and their relation to traumatic events. The therapist works to identify intrapsychic conflicts, intense negative affects, and defense mechanisms related to the PTSD syndrome using a psychodynamic formulation that provides a framework for intervention. The transference provides a forum for patients to address feelings of mistrust, difficulties with authority, fears of abuse, angry and guilty feelings, and fantasies.

What is the effect on comorbid personality disorder of brief panic-focused psychotherapy in patients with panic disorder?

BACKGROUND

No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD.

METHODS

In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity.

RESULTS

37 and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). Although there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (P = .007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost).

CONCLUSIONS

PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

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.

Are there subtypes of panic disorder? An interpersonal perspective

OBJECTIVE

Panic disorder (PD) is associated with significant personal, social, and economic costs. However, little is known about specific interpersonal dysfunctions that characterize the PD population. The current study systematically examined these interpersonal dysfunctions.

METHOD

The present analyses included 194 patients with PD out of a sample of 201 who were randomized to cognitive-behavioral therapy, panic-focused psychodynamic psychotherapy, or applied relaxation training. Interpersonal dysfunction was measured with the Inventory of Interpersonal Problems-Circumplex (Horowitz, Alden, Wiggins, & Pincus, 2000).

RESULTS

Individuals with PD reported greater levels of interpersonal distress than that of a normative cohort (especially when PD was accompanied by agoraphobia), but lower than that of a cohort of patients with major depression. There was no single interpersonal profile that characterized PD patients. Symptom-based clusters (with vs. without agoraphobia) could not be discriminated on core or central interpersonal problems. Rather, as revealed by cluster analysis based on the pathoplasticity framework, there were 2 empirically derived interpersonal clusters among PD patients that were not accounted for by symptom severity and were opposite in nature: domineering-intrusive and nonassertive. The empirically derived interpersonal clusters appear to be of clinical utility in predicting alliance development throughout treatment: Although the domineering-intrusive cluster did not show any changes in the alliance throughout treatment, the nonassertive cluster showed a process of significant strengthening of the alliance.

CONCLUSIONS

Empirically derived interpersonal clusters in PD provide clinically useful and nonredundant information about individuals with PD.

Interpersonal Factors Are Associated with Lower Therapist Adherence in Cognitive-Behavioural Therapy for Panic Disorder

OBJECTIVE

The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive-behavioural treatment (CBT) manual were tested.

METHOD

Thirty-eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24-session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the structured clinical interview for DSM-IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory-short form.

RESULTS

The higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence.

CONCLUSIONS

Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Patients' behavioural resistance to therapy may make it more difficult for cognitive-behavioural clinicians to adhere to a structured treatment protocol and more likely for them to borrow interventions from outside the CBT model. Patients' Axis II traits may make adherence to treatment CBT protocol more difficult, although whether this is true varies across therapists. Therapists' adherence to a structured protocol and borrowing from outside of the CBT model do not appear to be affected by disorder severity or Axis I comorbidity.

Critical review of outcome research on interpersonal psychotherapy for anxiety disorders

BACKGROUND

Interpersonal psychotherapy (IPT) has demonstrated efficacy in treating mood and eating disorders. This article critically reviews outcome research testing IPT for anxiety disorders, a diagnostic area where cognitive behavioral therapy (CBT) has dominated research and treatment.

METHODS

A literature search identified six open and five controlled trials of IPT for social anxiety disorder (SAD), panic disorder, and posttraumatic stress disorder.

RESULTS

Studies were generally small, underpowered, and sometimes methodologically compromised. Nonetheless, minimally adapted from its standard depression strategies, IPT for anxiety disorders yielded positive results in open trials for the three diagnoses. In controlled trials, IPT fared better than waiting list (N = 2), was equipotent to supportive psychodynamic psychotherapy (N = 1), but less efficacious than CBT for SAD (N = 1), and CBT for panic disorder (N = 1) in a methodologically complicated study. IPT equaled CBT in a group residential format (N = 1).

CONCLUSIONS

IPT shows some promise for anxiety disorders but has thus far shown no advantages in controlled trials relative to other therapies. Methodological and ecological issues have complicated testing of IPT for anxiety disorders, clouding some findings. The authors discuss difficulties of conducting non-CBT research in a CBT-dominated area, investigator bias, and the probable need to further modify IPT for anxiety disorders. Untested therapies deserve the fairest possible testing.

Teaching clinical research on psychodynamic psychotherapy to psychiatric residents

This article describes a course, Clinical Research in Psychotherapy, taught to PGY-3 residents at the New York Presbyterian Hospital-Weill Cornell Medical College. The course addresses existing research in outcome and process in psychotherapy, concepts important in research design, and assessment of results of psychotherapy research. It also explores how knowledge of research can enhance clinical practice. The authors believe that teaching psychotherapy research to residents will aid the development of a generation of clinicians who can best recognize the value of a psychodynamic approach for patients.

A quality-based review of randomized controlled trials of cognitive-behavioral therapy for depression: an assessment and metaregression

OBJECTIVE

The authors assessed the methodological quality of randomized controlled trials of cognitive-behavioral therapy (CBT) for depression using the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). They then compared the quality of CBT trials with that of psychodynamic therapy trials, predicting that CBT trials would have higher quality. The authors also sought to examine the relationship between quality and outcome in the CBT trials.

METHOD

An independent-samples t test was used to compare CBT and psychodynamic therapy trials for average total quality score. Metaregression was used to examine the relationship between quality score and effect size in the CBT trials.

RESULTS

A total of 120 trials of CBT for depression met inclusion criteria. Their mean total quality score on the RCT-PQRS was 25.7 (SD=8.90), which falls into the lower range of adequate quality. In contrast to our prediction, no significant difference was observed in overall quality between CBT and psychodynamic therapy trials. Lower quality was related to both larger effect sizes and greater variability of effect sizes when analyzed across all available comparisons to CBT.

CONCLUSIONS

On average, randomized controlled trials of CBT and of psychodynamic therapy did not differ significantly in quality. In CBT trials, low quality appeared to reduce the reliability and validity of trial results. These findings highlight the importance of discerning quality in individual psychotherapy trials and also point toward specific methodological standards for the future.

Psychometric properties of the mobility inventory for agoraphobia: convergent, discriminant, and criterion-related validity

Aims of this study were (a) to summarize the psychometric literature on the Mobility Inventory for Agoraphobia (MIA), (b) to examine the convergent and discriminant validity of the MIA's Avoidance Alone and Avoidance Accompanied rating scales relative to clinical severity ratings of anxiety disorders from the Anxiety Disorders Interview Schedule (ADIS), and (c) to establish a cutoff score indicative of interviewers' diagnosis of agoraphobia for the Avoidance Alone scale. A meta-analytic synthesis of 10 published studies yielded positive evidence for internal consistency and convergent and discriminant validity of the scales. Participants in the present study were 129 people with a diagnosis of panic disorder. Internal consistency was excellent for this sample, α=.95 for AAC and .96 for AAL. When the MIA scales were correlated with interviewer ratings, evidence for convergent and discriminant validity for AAL was strong (convergent r with agoraphobia severity ratings=.63 vs. discriminant rs of .10-.29 for other anxiety disorders) and more modest but still positive for AAC (.54 vs. .01-.37). Receiver operating curve analysis indicated that the optimal operating point for AAL as an indicator of ADIS agoraphobia diagnosis was 1.61, which yielded sensitivity of .87 and specificity of .73.

A quality-based review of randomized controlled trials of psychodynamic psychotherapy

OBJECTIVE

The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). The authors report results from application of the RCT-PQRS to 94 randomized controlled trials of psychodynamic psycho-therapy published between 1974 and May 2010.

METHOD

Five psychotherapy researchers from a range of therapeutic orientations rated a single published paper from each study.

RESULTS

The RCT-PQRS had good interrater reliability and internal consistency. The mean total quality score was 25.1 (SD=8.8). More recent studies had higher total quality scores. Sixty-three of 103 comparisons between psychodynamic psychotherapy and a nondynamic comparator were of "adequate" quality. Of 39 comparisons of a psychodynamic treatment and an "active" comparator, six showed dynamic treatment to be superior, five showed dynamic treatment to be inferior, and 28 showed no difference (few of which were powered for equivalence). Of 24 adequate comparisons of psychodynamic psychotherapy with an "inactive" comparator, 18 found dynamic treatment to be superior.

CONCLUSIONS

Existing randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of psychodynamic psychotherapy to an inactive comparator. This would be sufficient to make psychodynamic psychotherapy an "empirically validated" treatment (per American Psychological Association Division 12 standards) only if further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for specific disorders. We do not yet know what will emerge when other psychotherapies are subjected to this form of quality-based review.

Isolated sleep paralysis and fearful isolated sleep paralysis in outpatients with panic attacks

Isolated sleep paralysis (ISP) has received scant attention in clinical populations, and there has been little empirical consideration of the role of fear in ISP episodes. To facilitate research and clinical work in this area, the authors developed a reliable semistructured interview (the Fearful Isolated Sleep Paralysis Interview) to assess ISP and their proposed fearful ISP (FISP) episode criteria in 133 patients presenting for panic disorder treatment. Of these, 29.3% met lifetime ISP episode criteria, 20.3% met the authors' lifetime FISP episode criteria, and 12.8% met their recurrent FISP criteria. Both ISP and FISP were associated with minority status and comorbidity. However, only FISP was significantly associated with posttraumatic stress disorder, body mass, anxiety sensitivity, and mood and anxiety disorder symptomatology.

Does interpersonal loss preceding panic disorder onset moderate response to psychotherapy? An exploratory study

BACKGROUND

Little research has addressed moderators of treatment outcome for anxiety disorders, and none has considered interpersonal loss as a predictor of outcome.

PURPOSE

To examine the effect of interpersonal loss events within the 6 weeks preceding panic disorder onset as a moderator of outcome in a randomized controlled trial of Panic-Focused Psychodynamic Therapy (PFPP) and Applied Relaxation Therapy (ART). Researchers hypothesized that such loss events would predict better outcome in PFPP but would not affect ART outcome.

METHOD

Forty-nine subjects with panic disorder were randomly assigned to a 12-week course of PFPP or ART. Independent raters blinded to treatment condition and study hypotheses rated subjects on the Panic Disorder Severity Scale (PDSS) and Sheehan Disability Scale. Exploratory analyses assessed between-group effect size for PFPP and ART following standard moderator analytic procedures. The trial was conducted between February 2000 and January 2005.

RESULTS

Three quarters of subjects reported a narrowly defined interpersonal loss (LOSS) in the 6 weeks preceding panic disorder onset. These subjects had a mean (SD) duration of panic disorder of 8.2 (9.5) years. PFPP was more efficacious than ART, but LOSS did not moderate PFPP outcome. An unexpected finding was that LOSS moderated ART outcome: subjects without LOSS showed no response to ART (PDSS mean (SD) change score = 0.00 [2.90]), whereas LOSS had a pre-post mean (SD) change score of 4.29 (5.60). Neither examination of potential confounding variables nor sensitivity analyses of assumptions regarding attrition altered these findings.

CONCLUSIONS

Interpersonal loss events preceding onset of panic disorder were more common even than in prior studies. These losses moderated outcome in ART, a therapy that does not focus on such losses. Implications and the need for future research before incorporating these findings into clinical practice are discussed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00128388.

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.

Do comorbid personality disorders moderate panic-focused psychotherapy? An exploratory examination of the American Psychiatric Association practice guideline

OBJECTIVE

The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome.

METHOD

Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005.

RESULTS

Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity.

CONCLUSIONS

Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier NCT00128388.

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.

Theory and technique in psychodynamic treatment of panic disorder

The authors elaborate psychodynamic factors that are relevant to the treatment of panic disorder. They outline psychoanalytic concepts that were employed to develop a psychodynamic approach to panic disorder, including the idea of unconscious mental life and the existence of defense mechanisms, compromise formations, the pleasure principle, and the transference. The authors then describe a panic-focused psychodynamic treatment based on a psychodynamic formulation of panic. Clinical techniques used in this approach, such as working with transference and working through, are described. Finally, a case vignette is employed to illustrate the relevance of these factors to panic disorder and the use of this treatment.(The Journal of Psychotherapy Practice and Research 1999; 8:234-242)