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Psychodynamic Psychotherapy for Panic Disorder?

A randomized controlled trial yields positive results.

Psychoanalytic psychotherapists have long argued that their therapies are effective for panic disorder, but these claims have hitherto lacked the quality of evidence required by current standards. In this randomized, controlled clinical trial, 49 adults with DSM-IV panic disorder (mean number of Axis I comorbidities, 2; patients on stable antipanic medications, 9) underwent 12-week courses of twice-weekly panic-focused psychodynamic therapy (PFP) or applied relaxation training, a behavioral therapy less elaborate than cognitive-behavioral therapy. PFP involves three phases, addressing different issues: (1) unconscious issues thought to be associated with panic (e.g., separation, autonomy, and unacknowledged anger); (2) salient unconscious conflicts thought to contribute to panic vulnerability; and (3) separation- and anger-related conflicts that may re-emerge with termination.

Response was defined as a 40% decrease in scores on a scale measuring panic disorder severity. PFP was associated with a lower dropout rate than relaxation training (7% vs. 34%), greater reductions in functional impairment, and a higher rate of symptom response (73% vs. 39%), with a strong effect size. Adjustment for antipanic medications did not alter these outcomes.

Comment: This first-ever report of efficacy for PFP shows that controlled trials of psychodynamic psychotherapy are possible although difficult to conduct. The attrition rate, much lower than that reported in most CBT studies, indicates excellent tolerability and acceptance of the psychotherapy. The high rates of comorbid agoraphobia and depression (higher than in many previous studies) suggest real-world effectiveness of PFP. Studies are needed to determine how these changes endure and to compare PFP with CBT and medications. Different patients may be better suited to CBT or PFP, or the two psychotherapies may share elements that achieve response.

— Joel Yager, MD

Published in Journal Watch Psychiatry March 12, 2007

Citation(s):

Milrod B et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry 2007 Feb; 164:265-72.

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