Systematic Psychodynamic Research. Systematic study of psychodynamic treatments for panic disorder is in its infancy. As described above, a significant minority of patients fail to respond to the more extensively empirically tested treatments, and many patients experience residual symptoms after pharmacological and cognitive-behavior treatments (Nagy et al., 1989; Noyes et al., 1989, 1991; Pollack et al., 1993; Barlow et al., 2000). Thus, attention to psychodynamic issues may potentially provide further improvement for some patients.
Milrod and Shear (1991) found 35 cases in the literature with DSM-III-R panic disorder who were successfully treated with psychodynamic psychotherapy or psychoanalysis alone. Since then, other successful psychodynamic treatments for patients with panic disorder have been reported (Milrod, 1995; Stern, 1995; Renik, 1995; Busch et al., 1996; Milrod et al., 1996). Clinical reports cannot substitute for controlled clinical trials. Nonetheless, these reports suggest that psychodynamic treatment alone can bring symptomatic relief, as rapidly as psychopharmacologic or cognitive-behavioral interventions. This approach therefore deserves systematic study. As mentioned above, Wiborg and Dahl (1996) randomized controlled trial of psychodynamic psychotherapy in combination with clomipramine suggests the value of psychodynamic psychotherapy in reducing relapse in panic patients treated with clomipramine.
To further study a psychodynamic approach to panic disorder treatment in a systematic manner, other authors have developed clearly defined, panic-specific psy-chodynamic treatments in order to facilitate outcome research. One such approach shall be described below.
Panic-Focused Psychodynamic Psychotherapy (PFPP). PFPP is a modified form of psychodynamic psychotherapy that maintains central psychodynamic principles (Milrod et al., 1997). These include the core idea that unconscious mental dynamisms are responsible for biopsychological symptoms, such as panic attacks. The treatment makes use of fantasies, free association, and the centrality of the transference in effecting therapeutic change. The therapist focuses attention on all of these processes as they connect to the patient's experience of panic. Principles that have been observed to be common psychological dynamisms for panic patients, such as their difficulty with separation, inform interpretive efforts. Common factors with other psychodynamic psychotherapies include techniques of clarification, confrontation, and interpretation in and outside of the transference.
An open trial of PFPP has been completed (Milrod et al., 2001, 2000). In this study, PFPP followed a 24-session, psychodynamic psychotherapy program, delivered twice weekly in 45 to 50 min sessions, over 12 weeks. Twenty-one patients with primary DSM-IV panic disorder entered the treatment trial. Four patients dropped out. Sixteen of 21 patients experienced remission of panic and agoraphobia. Treatment completers with major depression (N = 8) also experienced remission of their depression. Symptomatic and quality of life improvements were substantial and consistent across all measured areas. Symptomatic gains were maintained over 6 months. While the sample size in this study was too small to draw firm conclusions, as a result of this pilot research, the authors concluded that psychodynamic psychotherapy appears to be a promising nonpharmacological treatment for panic disorder. A randomized controlled trial of PFPP conducted by the same group of researchers is currently underway. The clinical utility of this treatment approach for subpopulations of patients with panic disorder has yet to be tested. Empirical investigation must confirm these encouraging initial findings.
In summary, little attention has been paid to the intrapsychic aspects of panic disorder until recently. Based on reports in the literature, clinical experience, and some promising systematic research, there is encouraging evidence that a psychodynamic approach (that emphasizes unconscious mental processes, fantasy, free association, and interpretation of transference developed within psychotherapy) may be an important tool for optimal treatment of some patients with panic disorder. Psychodynamic psychotherapy may also be useful for residual symptoms, possibly linked to early life experiences, that continue to interfere with optimal emotional well-being and interpersonal functioning.
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