Fredric N. Busch

An empirical study of defense mechanisms in panic disorder

Psychodynamic factors have rarely been systematically studied in panic disorder, despite indications that these factors may be important in the understanding and treatment of panic. This is a report of a study using the Defense Mechanism Rating Scale to test the hypothesis that patients with panic disorder utilize particular defense mechanisms: reaction formation, undoing, and displacement. The use of defense mechanisms in 22 patients with primary panic disorder was compared with that of 22 patients with primary dysthymic disorder, based on Defense Mechanism Rating Scale ratings of psychodynamic interviews of these patients. Panic subjects scored significantly higher than dysthymics on the defenses of reaction formation and undoing, but not on the defense of displacement. The defense mechanisms found are consistent with a proposed psychodynamic formulation for panic disorder that emphasizes the panic patients difficulty in tolerating angry feelings toward significant others. Knowledge of these defense mechanisms can be useful for various treatment approaches in panic disorder.

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.

Long-term outcome of panic disorder treatment. A review of the literature.

This review was designed to provide a detailed analysis of long-term outcome data from treatment studies for panic disorder, with the goal of ascertaining differential efficacy of the available treatments. Studies were included if they were published after 1980 and if follow-up took place at least 6 months after treatment termination. Thirty-one studies were located. A variety of methodological problems were found in these studies, including lack of clarity of diagnosis, lack of clarity in the treatment administered, and inadequately tracked nonstudy treatments during the study and follow-up periods, which limited the information that could be obtained about long-term outcome. Long-term outcome studies that closely track the additional treatments that patients receive are necessary to draw more definitive conclusions about differential treatment efficacy for panic disorder. Available data suggest that there is limited evidence for long-term maintenance of short-term treatment gains in panic disorder patients in the absence of continued treatment.

Panic disorder and depression: A psychodynamic exploration of comorbidity

Eight of twenty‐one patients presenting for treatment in an open trial of brief psychodynamic psychotherapy for panic disorder also carried the diagnosis of major depression. For the patients who completed the study, depression remitted as well as panic disorder. The authors highlight psychodynamic factors that they hypothesize may contribute to the significant overlap between panic disorder and depression, and describe three videotaped cases to illustrate these points.

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. Fantasied 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.

Agoraphobia and panic states

he panel on agoraphobia and panic states, chaired by T Allan Compton, rvas a unique program for the American Psychoanalytic Association, as experts from other areas of psychiatry were invited to present their approaches and studies, afTording an opportunity for analysts to hear \arying perspectives on the treatment and etiology of these conditions. Michelle Craske presented the cognitive-behavioral perspective; Donald Klein represented the neurophysiological approach; Jerrold Rosenbaum reviewed data on behavioral inhibition, a possible marker for panic disorder in children; and Martin Silverman advanced a multidimensional perspective. The panel grappled with a number of interesting issues: Do panic and agoraphobia represent a range of syndromes requiring a variety of treatment approaches, or does one size fit all? What is the role of psychoanalysis in the treatment of panic and agoraphobia when other treatment approaches have been found to be effective? Should analysts proceed with systematic research studies comparable to what has been done with other a p proaches! Allan Compton opened with a review of the current state of treatments of agoraphobia/panic, which sewed to alert analysts that the psychoanalytic or psychodynamic approach is respected by only a limited segment of those concerned with mental health. Two approaches are widely respected as theories and treatments by the public, government agencies, and the insurance indusq: the neurophysiological, or psychopharmacological, and the cognitive-behavioral. The former sees panic as stemming from a neurophysiological abnormality, probably of genetic origin, best treated by appropriate pharmacological

Combined Treatment of Depression

Multiple medications and some forms of psychotherapy have demonstrated efficacy in the treatment of depression. However, despite these interventions, many patients continue to respond only partially to available treatments and nonadherence to medication is common, adding to the tendency of depression to recur. Many clinicians believe that a combination of medication and psychotherapy provides the greatest potential for long-term relief of depression, and a number of studies have focused on the relative value of combined compared to single treatments. Given our current state of knowledge, for which patients should a combination of medication and psychotherapy be recommended and employed? The American Psychiatric Association Practice guideline for the treatment of patients with major depressive disorder identifies a broad range of conditions for which combined treatment should be considered (Box 1): “Combining a depression-focused psychotherapy and pharmacotherapy may be a useful initial treatment choice for patients with moderate to severe major depressive disorder. Other indications for combined treatment include chronic forms of depression, psychosocial issues, intrapsychic conflict, interpersonal problems, or a co-occurring Axis II disorder. In addition, patients who have had a history of only partial response to adequate trials of single treatment modalities may benefit from combined treatment. Poor adherence with pharmacotherapy may also warrant combined treatment with medications and psychotherapy focused on treatment adherence.” There are several reasons to believe that medication and psychotherapy should be utilized together for treatment of depression. These approaches probably affect different areas of the brain, potentially creating a synergistic neurophysiologic effect. Given that different patients demonstrate different responses to various treatments, combining two treatments increases the likelihood patients will respond to at least

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.

THE ONGOING STRUGGLE FOR PSYCHOANALYTIC RESEARCH: SOME STEPS FORWARD

Although the need for psychoanalytic research is increasingly acknowledged, many psychoanalysts remain resistant to the performance and findings of this research. Objections to research include a continuing mistrust of research tools and approaches, combined with a belief in the effectiveness of psychoanalytic treatments based on clinical lore and individual experience. Furthermore, as psychoanalytic literature continues to function within its own separate domain, even well-read psychoanalysts can be sequestered from central scientific conversations occurring in the larger literature about mental health. In part due to these factors, few adequate studies of psychoanalytic treatment approaches have been performed. The lack of efficacy research has added to the marginalization of psychoanalytic treatments. Fortunately, in recent years groups of clinicians and researchers have begun to study psychoanalytic treatments, particularly approaches to specific disorders. In this context, this issue provides a welcome addition to the literature in the trailblazing work and papers of Lemma, Target, & Fonagy and Gelman, McKay, & Marks. They have developed an exportable and specific psychoanalytic psychotherapy, which has been employed in the UKs National Health Service Improving Access to Psychological Therapies (IAPT) programme. Work on manualized treatments, such as the Dynamic Interpersonal Therapy of Lemma et al., has allowed psychoanalysts to better clarify and illustrate their treatment approaches. Thus psychoanalytic research, in addition to assessing efficacy, can potentially lead to the development of more effective and rapid relief of symptoms, in a broader population of patients.

An Integrated Model of Panic Disorder

Clinicians are shifting away from dualistic conceptions of mind and brain toward a view of psychiatric illnesses as involving interactions between biology, mind, and environment. Our understanding of panic disorder benefits from such an integrative analysis. We review genetic, neurochemical, and neuroimaging data on panic disorder, along with a series of biological and psychological models. We propose that separation and suffocation alarm systems cut across various models, and we suggest how biological, psychological, and environmental interactions can lead to panic onset and persistence. Separation and suffocation alarm systems may become sensitized due to environmental events, an inborn vulnerability, or both. These oversensitized systems create a vulnerability to environmental experiences of loss and intrusion and to frightening psychological experiences of separation and suffocation. In individuals with this vulnerability, angry feelings and fantasies, often unconscious, further intensify fears of loss of or intrusion by attachment figures, triggering separation and suffocation alarms and associated panic attacks. This model provides a basis for understanding how psychological and biological approaches affect different components of these interactive systems, leading to relief of panic symptoms. We discuss implications of this integrative model for current clinical practice and future research.