Larry S. Sandberg

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.

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

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 Freuds actual neurosis, Marty and DeMuzans pensee operatoire, Kleins unconscious fantasy, Bions alpha function, Buccis 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.

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.

I WRITE TO KNOW WHAT I THINK : A FOUR-YEAR WRITING CURRICULUM

The four-year writing curriculum of the Columbia Center for Psychoanalytic Training and Research has as its main objective to teach candidates to learn about analysis through writing. Learning to write about analyses ultimately entails learning to clarify and then express how one thinks and functions as an analyst. Since its inception ten years ago, the program has evolved into its current structure, a stepwise approach through the years of candidate training based on a didactic method called “layering.” For each level of the course, candidates typical writing difficulties are examined, and examples given of write-ups and how they were used in teaching. The essential role of the faculty experience is also described.

Panic-Focused Psychodynamic Psychotherapy in a Woman with Panic Disorder and Generalized Anxiety Disorder

Panic-focused psychodynamic psychotherapy (PFPP) is a 24-session, twice-weekly (12 weeks), manualized psychoanalytic psychotherapy with demonstrated preliminary efficacy for panic disorder (PD).1,2 Given the substantial morbidity and the health care utilization of the PD population,3,4 coupled with the sizable proportion of such patients who do not respond (or respond inadequately) to alternate treatments (cognitive-behavioral therapy [CBT] and drug therapy),5−7 PFPP may offer clinicians an additional tool for their therapeutic armamentarium. It may also facilitate a rapprochement between academic psychiatry and psychodynamic perspectives, and a reassessment of the role of psychodynamic therapy as part of the educational experience

On the Therapeutic Action of SSRI Medications

R ichard M. Gottlieb’s “A Psychoanalytic Hypothesis Concerning the Therapeutic Action of SSRI Medications” (JAPA 50/3, pp. 969–971) has drawn considerable comment on a topic at the interface of psychoanalysis and psychopharmacology. Seldom has such a brief contribution—it is barely two and a half pages long—generated such substantial discussion. Following are five letters addressing the article and a reply by its author. —Stuart T. Hauser

On Psychodynamic Meanings of Psychiatric Treatment: Discussion of “From Dyad to Triad”

Dr. Bar-Haim has covered vast territory in her contribution “From Dyad to Triad: On Psychodynamic Meanings of Psychiatric Treatment,” (this issue) and I welcome the opportunity to offer my thoughts on her contribution and this important topic more generally. The issues touched upon include the various meanings of psychiatric treatment for patient and therapist; factors that impact compliance; resistances to suggesting medication consultation on the part of the therapist; challenges of the prescribing therapist; the role of a “disease” model in mental suffering; the overdetermined meaning of “symptom”; and, most important, recommendations for establishing effective treatment when a treatment triangle exists. I address some of these issues and comment on two clinical vignettes to illustrate my way of thinking.

Commentary on “Toward a Neuroscience of Empathy: Integrating Affective and Cognitive Perspectives”

Larry S. Sandberg and Fredric N. Busch: Weill Medical College of Cornell University, New York; Columbia University, Center for Psychoanalytic Training and Research, New York, NY, U.S.A.. We are pleased to offer commentary on the scholarly and ambitious contribution of Douglas Watt to the neuroscience of empathy. In the brief space allotted, we will be selective in approaching the task, first addressing what we see as some of the central arguments of the paper and then turning to clinical psychoanalysis in an effort to encourage the kind of interdisciplinary dialogue for which this journal is designed. Implicit in this approach is the view that psychoanalytic perspectives on empathy are relevant to any comprehensive neuroscience of this complex phenomenon. We shall critique Watt’s perspectives on the use of animal data for a model of human neurophysiological and psychological functioning, the idea of contagion and its subcortical roots as “paradigmatic” for empathy, and the notion of gated resonance induction. Watt’s conception of empathy will then be contrasted with a view that emphasizes the importance of mirror neuron systems and embodied simulation. We then turn to data from the psychoanalytic literature before suggesting a tentative, albeit partial, synthesis of the current neuroscientific data in light of empirical psychoanalytic evidence. This synthesis acknowledges the omnipresent role of contagion while placing greater emphasis on the concepts of simulation, embodiment, and action as expressed through the closely related phenomena of enactment and transference/countertransference in the clinical situation.