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Panic-focused psychodynamic psychotherapy–extended range
Panic-focused psychodynamic psychotherapy extended range
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Fredric N. Busch1 and Barbara L. Milrod1,2,3 1 Weill Cornell Medical College, New York, NY, United States, 2New York Psychoanalytic Institute, New York, NY, United States, 3Columbia University Center for Psychoanalytic Training and Research, New York, NY, United States
Introduction Panic-focused psychodynamic psychotherapy (PFPP) was developed to elaborate core psychodynamic conflicts and meanings of symptoms associated with panic disorder and agoraphobia and to modify more open-ended psychodynamic approaches to focus on panic symptoms (Busch, Milrod, Singer, & Aronson, 2012). This treatment has been extended (Panic-focused psychodynamic psychotherapy extended range; PFPP-XR) to address a range of DSM 5 (American Psychiatric Association, 2013) anxiety disorders, cluster C personality disorders, and posttraumatic stress disorder (PTSD), with the identification of dynamisms that appear prominently in these various disorders (Busch et al., 2012). PFPP has been subjected to efficacy testing in randomized controlled trials as a 12-week, 24-session psychotherapy and has demonstrated efficacy for treatment of panic disorder with and without agoraphobia (Milrod et al., 2007; Subic-Wrana, Knebel, & Beutel, 2010). It has also been studied in comparison to cognitive-behavioral therapy and applied relaxation training (Milrod et al., 2016) and meets evidence-based medicine criteria.
A psychodynamic formulation for panic and anxiety disorders Busch, Cooper, Klerman, Shapiro, and Shear (1991), Shear, Cooper, Klerman, Busch, and Shapiro (1993), and Milrod, Busch, Cooper, and Shapiro (1997) articulated a series of dynamic psychological constellations underlying panic disorder. According to this psychodynamic formulation, a combination of genetically based vulnerabilities and significant developmental experiences contributes to psychological vulnerabilities to panic disorder onset and persistence as well as a range of anxiety disorders. Children in these circumstances feel particularly threatened by separation and develop a sense of fearful dependency on caregivers, who are experienced as (and often are in some ways) unreliable or rejecting. Normal efforts to develop autonomy create anxiety and conflict because of their link to separation Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00008-8 © 2019 Elsevier Inc. All rights reserved.
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and symbolic loss of primary attachment figures. Such strivings may well have constituted high-anxiety situations for parents in childhood because of their own separation and attachment dysregulations. The children become frightened and guilty about angry feelings and fantasies, fearing that they will disrupt or damage relationships with caregivers or parents. Defense mechanisms such as denial, reaction formation, and undoing are triggered in an unconscious effort to reduce the threat from angry feelings and fantasies and to ensure a greater sense of safety in core attachment relationships (Busch, Shear, Cooper, Shapiro, & Leon, 1995), but the potential conscious emergence of these seemingly disruptive fantasies causes persistent anxiety and guilt. In addition, mentalization, that is, the capacity to conceive of behaviors as deriving from mental states (Fonagy & Target, 1997), is disrupted in these anxious patients by avoidance of feelings and frightening experiences with caretakers. The lack of capacity to mentalize interferes with the ability to identify relevant feelings and thoughts occurring in intense attachment relationships, often contributing to conflicts being expressed in somatic form. In adulthood, perceived attachment threats cause regression and a surge of anger, anxiety, and guilt, along with a shutdown of mentalization capacity that cannot be readily identified or managed, leading ultimately to panic. The resulting panic attacks can function as punishment for angry fantasies, as a defense against anger through presenting the self as weak and damaged (often a calming fantasy for these patients), and as a plea for more regressive, childlike care from core attachment figures via appealing for help. Patients with other DSM 5 anxiety disorders have dynamic constellations that overlap in varying degrees with those typically found in patients with panic disorder. Patients with anxiety disorders are prone to viewing themselves as inadequate and ineffective, believing that another person is essential for their safety or even survival. These self-representations are triggered by fears of greater autonomy or of angry feelings, which are often perceived as threats to close attachment relationships. In addition, specific conflicts can be more characteristically prominent among patients with individual DSM 5 anxiety disorders. For example, patients with social phobia often struggle with an underlying sense of inadequacy that triggers compensatory grandiose fantasies and exhibitionistic wishes. Grandiose and exhibitionistic fantasies can create conflict and guilt and can lead to feelings of disappointment and excessive self-criticism in actual social situations, fueling anxiety. In generalized anxiety disorder, patients are often fearful of the conscious emergence of conflicted feelings and fantasies and maintain a constant state of vigilance in an effort to prevent fantasized dangers that could arise if they were to relax. Worries about finances and somatic concerns can also function as defenses against unacceptable feelings and fantasies. Chronic worrying and hypervigilance can also emerge from insecure, frightening, or unstable early relationships. Children may develop chronic fears that their close attachments with others can be easily disrupted by their own feelings and fantasies or by the fragility of others. The PFPPXR manual describes specific dynamics of various anxiety disorders in greater depths along with approaches to these disorders (Busch et al., 2012).
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Description of panic-focused psychodynamic psychotherapy extended range PFPP-XR differs from more open-ended psychodynamic psychotherapeutic approaches, focusing on the feelings, circumstances, and meanings of panic attacks, severe anxiety states, and phobic avoidance (Busch et al., 2012; Milrod et al., 1997). This information is used to identify and develop a psychodynamic formulation pertaining to the individual patient’s anxiety symptoms. Sessions initially are open-ended with the therapist exploring the themes that the patient brings up. However, anxiety symptoms and their impact are focused on consistently throughout the treatment. If the patient does not discuss his or her anxiety symptoms or related dynamics in the course of the session, the therapist eventually turns the patient’s attention to them. Seemingly unrelated emergent themes are consistently linked to anxiety symptoms and their underlying dynamics, including their emergence in the transference. This time-limited treatment requires a more rapid development of a formulation surrounding the underlying meanings of panic and anxiety than typically occurs in more traditional, open-ended psychodynamic psychotherapy. PFPP-XR is divided into three phases, although elements of each phase can occur throughout the treatment. In the first phase the therapeutic focus is on episodes of panic or severe anxiety; exploring the patient’s circumstances, feelings, and thoughts surrounding symptoms; and beginning to identify underlying fantasies and meanings of symptoms. The therapist works with the patient to demonstrate that symptoms have powerful emotional meanings and context rather than coming out of the blue; this work serves to improve reflective functioning. The patient’s developmental history is explored as it pertains to anxiety, and the therapist begins to discuss this overarching psychological context in terms of its potential relevance to symptoms. The therapist develops and presents a preliminary psychodynamic formulation about the meaning and dynamics of the patient’s anxiety or panic during this phase, usually within the first few sessions, typically involving themes and conflicts surrounding separation, anger, sexuality, and guilty self-punishment. This formulation provides a framework for further therapeutic work and will be added to and modified over the course of treatment. In the middle phase of therapy the therapist helps the patient to identify additional fantasies, conflicts, and developmental experiences and their relevance to prominent anxiety symptoms. The intensification of the transference during this phase allows the therapist to highlight core conflicts as they emerge in the relationship with the therapist. The goals are to reduce anxiety vulnerability with improved identification of anxiety precipitants, meanings, and conflicted feelings and fantasies; better tolerance of the patient’s own anger; and an enhanced ability to reflect on emotions and their meaning (reflective function) (Fonagy & Target, 1997). In the termination phase the therapist explores the patient’s mixed feelings about ending the therapy. If the patient has not addressed termination upon entering the final third of treatment, the therapist will raise the issue at that point. Conflicts and
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fears surrounding attachment and separation can be further explored as they emerge in the context of the upcoming separation from the therapist. These fears and conflicts can be articulated and can be understood and better tolerated in the context of the relationship with the therapist. Active focus on termination increases the patient’s capacity to manage separation, anger, guilt, and associated fantasies in ways that improve reflective functioning, which may be protective against reoccurrence of anxiety after therapy ends.
Studies of panic-focused psychodynamic psychotherapy In an open clinical trial conducted at Weill Cornell Medical College, 21 patients with primary DSM 4 (American Psychiatric Association, 1994) panic disorder with or without agoraphobia were treated with twice weekly, 24-session PFPP (Milrod et al., 2000, 2001). At the end of treatment, 16 of 21 patients showed remission of panic and agoraphobia, defined by multisite panic disorder study criteria (Barlow, Gorman, Shear, & Woods, 2000). Depression remitted in patients with comorbid major depression (N 5 8). Patients demonstrated substantial improvements in symptoms and psychosocial function [within-group effect size (ES) 5 2.08 in the primary outcome measure, the Panic Disorder Severity Scale (PDSS); Shear et al., 1997], which persisted at 6-month follow-up. Milrod et al. (2007) studied 49 patients with primary DSM 4 panic disorder with or without agoraphobia, diagnosed with the Anxiety Disorders Interview Schedule (Brown, DiNardo, & Barlow, 1995), who were randomized to either PFPP or applied relaxation therapy (ART) (Cerny et al., 1984). For patients receiving medication (18%) the dose and type of medication were kept constant. Patients were excluded if they were in another psychotherapy, and those entering the study could not engage in nonstudy psychotherapy during the treatment. Patients with severe agoraphobia, comorbid major depression, and personality disorder comorbidities were included, whereas patients with psychosis, bipolar disorder, and substance abuse (6 months remission necessary) were excluded. PFPP and ART were conducted twice weekly in 24 sessions. ART consisted of a three-session cognitive explanation about panic disorder (Cerny et al., 1984), progressive muscle relaxation techniques, and in vivo exposure to anxiety-inducing situations. Adherence ratings were assessed on three sessions from each treatment and indicated high adherence in both treatments. The ART group contained a higher proportion of men (47% vs 15%; two-tailed Fisher’s exact text, P 5 0.03), but otherwise, treatment groups were matched on demographic and clinical variables. No significant between-group differences were found with symptoms of anxiety and depression, as measured by the Hamilton Depression Rating Scale (Hamilton, 1960; P 5 0.07) and the Hamilton Anxiety Rating Scale (Hamilton, 1959; P 5 0.58). With response defined as a 40% decrease in the total PDSS score from baseline (Barlow et al., 2000), PFPP demonstrated a significantly higher response rate than ART (73% vs 39%; P 5 0.016). Subjects in
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the PFPP condition experienced significantly greater improvement in panic symptoms, as assessed by the PDSS (P 5 0.002), and psychosocial function, as measured by the Sheehan Disability Scale (Sheehan, 1983; P 5 0.014). PFPP was well tolerated, with a 7% (2 of 26 subjects) dropout rate. PFPP was the first psychoanalytic treatment to demonstrate efficacy for treatment of an axis I anxiety disorder (DSM 4 panic disorder and agoraphobia). In a pilot study utilizing data from the controlled trial described above, Rudden, Milrod, Target, Ackerman, and Graf (2006) studied reflective function and panicspecific reflective functioning (PSRF). PSRF was developed as a measure of the extent to which patients are aware of the link between panic and anxiety symptoms and underlying emotional content. Patients treated with PFPP demonstrated a significant improvement in PSRF from baseline to posttreatment, but those treated with ART did not. However, in this pilot study, which was underpowered, the degree of change in panic severity on the PDSS did not correlate with the degree of change in the PSRF, nor was the design appropriate to assess mechanisms. Milrod et al. (2016) conducted a randomized controlled trial of 201 patients with primary DSM 4 panic disorder with or without agoraphobia at two sites (Weill Cornell Medical College and the University of Pennsylvania) comparing PFPP, cognitive-behavioral therapy (CBT), and ART. Patients were included if they had had more than one panic attack per week in the preceding month as assessed by the ADIS IV Lifetime Version (Brown et al., 1995). Patients with active substance dependence, history of bipolar disorder or psychosis, acute suicidality, or organic mental syndrome were excluded. Patients on medication were included if doses had been stable for at least 2 months. The medication was monitored throughout the course of treatment, and ongoing psychotherapy was prohibited. Patients received 19 24 sessions over 16 weeks, lasting 45 50 minutes. CBT followed the protocol of panic control therapy (Craske, Barlow, & Meadows, 2000), modified by Chambless and Schwalberg to match the number of sessions in this study. This treatment contains (1) psychoeducation about anxiety and panic disorder; (2) identification and correction of maladaptive thoughts about anxiety and panic; (3) training in slow, diaphragmatic breathing; and (4) exposure to bodily sensations designed to mimic those of anxiety and panic (interoceptive exposure). ART was more active, with a more rigorous in vivo exposure protocol than in the Milrod et al. (2007) trial, and PFPP was employed as per the treatment described in this chapter. Response was defined as 40% reduction from the baseline PDSS score (Shear et al., 1997), the primary outcome measure. Adherence ratings were assessed by modality-specific rating scales by trained raters. Patients were found to have high comorbidity, including 80% with moderate to severe agoraphobia, 73% with more than one comorbid axis I disorder, 68% with at least one additional anxiety disorder, and 48% with axis II comorbidity on the SCID-II (First, Spitzer, Gibbon, Williams, & Benjamin, 1994). Relative to the Cornell sample, the Penn patients were found to have higher baseline severity of panic disorder on the PDSS, had less education, were younger, and were less racially and ethnically diverse. There were significant site by treatment differences in the effects of psychotherapies. Cornell patients improved at similar rates across
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all three treatments, whereas Penn patients improved significantly faster in ART and CBT than in PFPP. At treatment termination, Cornell patients responded better to PFPP and CBT compared to ART, whereas Penn patients did not show a differential response across treatments. Overall response rates across both sites were 46% for ART, 63% for CBT, and 59% for PFPP. Dropout rates were significantly higher for ART, which did not vary by site, and patients who were most symptomatic dropped out of ART significantly more (69% in ART, 26% in PFPP, 24% in CBT, P 5 0.013). Medication use, which was sevenfold higher at the Penn site, did not account for all of the differences in treatment effect. The underperformance of PFPP at Penn might reflect its novelty for the psychodynamic therapists there or might reflect the influence of other process factors.
PFPP-XR case example Mr. A was a 40-year-old man who directed a division of computer programmers at a tech company, was in his second marriage, and had a 5-year-old daughter from his first marriage. He had his most recent panic attack 2 days before his 40th birthday, 6 weeks before he entered treatment. He was diagnosed with panic disorder with agoraphobia, social phobia, and generalized anxiety disorder on the ADIS-IVL (Brown et al., 1995) and was randomized to a 24-session, 12-week treatment with PFPP as part of the psychotherapies for panic disorder study.
Phase I In starting the treatment, the therapist explored the circumstances and feelings surrounding panic onset while attending to the meaning of symptoms. Mr. A reported that he had recently found his work extremely stressful. He acknowledged wanting to be the perfect boss and had struggled with expectations from the company that he reprimand or fire several of his employees. The necessity of doing so had increased because of financial cutbacks in his division, which he attributed to competition from other companies and poor management of his own company. He had hoped to turn around some of these problems when he had become head of his division, but it had not gone as he had expected. He felt responsible and guilty about his inability to fix the problems even as he acknowledged that he had a limited ability to control the situation. He denied being angry at the company managers, despite blaming them for many of the difficulties in his job. On the day of his panic attack, he had to fire someone and had a surge of guilt, feeling that he had let the employee down. He described it as the most stressful day in his life. When he experienced the onset of numbness and paresthesias in his arms and legs along with twitching and severe anxiety, he thought he was having a stroke and went to the emergency department, where he was medically cleared and told that he was likely having a panic attack. Mr. A’s first panic attack had occurred 4 years before, when he was at his prior job, which was also very stressful. He was getting divorced after finding out that
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his then-wife was involved in an affair with a man whom she eventually married. Mr. A reported that an additional stress in the period between his past and recent panic episodes had been tensions with his ex-wife regarding custody and financial arrangements for their daughter. His ex-wife recurrently threatened to prevent Mr. A’s visits with his daughter, sometimes refusing to let the child go. On one of these occasions, about 2 years previously, his ex-wife called the police after a particularly severe argument. Mr. A was arrested and charged with assault, although he denied that this had occurred. He was eventually cleared of all charges but had to go through a lengthy trial that led to the loss of his prior job. Since that time, he had remained very tense and wary when seeing his ex-wife, although their conflicts about visits had not been as severe. In addition to his struggles at work and with his ex-wife, Mr. A reported that he was grappling with long-standing demands from his mother that he pay more attention to her. In this context the therapist explored the patient’s developmental history in greater depth. Mr. A reported that his early environment was repeatedly disrupted. His parents did not believe that the metropolitan area that he was growing up in was safe, so they sent him to live with his grandparents in a Caribbean country from ages 4 to 8. He returned to live with his parents but felt lost and confused in his third-grade class in school. He then was sent to live with an aunt and uncle in another metropolitan area for 2 years, where his academic work improved. His parents divorced when he was 14, and he was sent to military school from 8th to 11th grade. When he was back home, he felt pressure to take care of his mother, who remained embittered about her divorce, which was precipitated in part by his father having an affair. Mr. A felt that he had become his mother’s counselor and needed to be the man of the family. He believed that he had to hold in his own thoughts and feelings to protect her. Related problems occurred when his mother, a nurse, took care of an older man who was verbally abusive to her. Mr. A and his mother moved into a room in the man’s house for a period. Mr. A was exposed to the verbal abuse but was not allowed to respond. He reported that he had learned early on as part of his culture that he was supposed to respect authority and not complain. Mr. A was able to fairly readily link his panic attacks to issues related to his mother. His mother criticized his ex-wife for not having his mother more involved in their lives and was now very critical of Mr. A for trying to set limits on her involvement with his new wife. It emerged that Mr. A believed that his mother was self-centered and maintained a victim stance. She had had an accident 10 years previously in which her leg was injured, and she had successfully pursued a legal case. However, he believed that afterward, his mother made little effort to improve her situation, remaining homebound, complaining about her fate, and making demands on Mr. A to spend time with her. During the fifth session, the therapist offered a preliminary formulation to Mr. A regarding his panic attacks and generalized anxiety. The therapist suggested that Mr. A’s wish to please others and need for perfection had developed in the context of efforts to appease his parents after he felt abandoned as a child when sent to live with relatives. The need to be perfect, however, placed undue pressure on him,
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particularly in the context of the problems in his current life, including the demands of his job, mother, and ex-wife. Complicating his abandonment fears, Mr. A struggled with angry feelings toward the managers at work, his mother, and his ex-wife, but he typically denied being angry, believing that such feelings did not show respect for others. The therapist suggested that Mr. A was very frightened of his anger and that his panic attacks stemmed from fears of his anger and being abandoned. Mr. A reported that his father was demanding and that contact with him was limited. An English teacher, Mr. A’s father was very frustrated with his son’s difficulties in spelling and writing. Mr. A recalled a terrifying incident in which his father chased him around a table when he was 8 years old when he misspelled a word. His father grabbed him, opened the door, and was going to throw him out when his mother intervened. He had had a rapprochement with his father in his early 20s after his father attended a therapy course recommended by Mr. A. Mr. A described his first wife as “feisty” and as having said that she was frustrated that he would not make more efforts to defend himself. Marital stresses were created by struggles for control with his mother, who demanded his time and attention. His ex-wife was angry that he did not set better limits with his mother. Mr. A stated that he was attracted to women who had overcome adversity. His second wife, whom he had married 2 years previously, had lost her mother and was estranged from her father. He described her as very “up front” and said the relationship was going well. Mr. A worked to set limits with his mother, but he believed that his mother recurrently attempted to punish him for this by being withholding and critical, triggering intense guilt. On Mother’s Day, his mother had adopted an “oh don’t bother with me” attitude when Mr. A said that he did not have time to take her out to a restaurant, behavior that he experienced as guilt inducing, passive aggressive, and manipulative. He felt that he was disappointing her by not spending more time with her.
Phase II In phase II the therapist further explored the dynamics surrounding Mr. A’s panic and difficulties with relationships. Mr. A described how at some point, he learned that the best way to be liked was to be “perfect,” including being the perfect son and perfect boss, always nice to others. He made efforts to please people, with the idea that then they would like him. In this context, the therapist and Mr. A recognized that his need to discipline people at work and set boundaries with his mother created intense anxiety. Mr. A talked about his ongoing struggles at work, and the therapist focused on what Mr. A was experiencing. He felt pressured by his bosses to do things he did not agree with, which he described as “dog eat dog.” The manager who had made Mr. A head of his division left the company, and the new leader did not have the same ethics. Mr. A blamed himself for the problems in his division, and the therapist pointed out that he had been placed in a very difficult position.
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The most difficult interactions with employees occurred when Mr. A had to critique, reprimand, or increase pressure on them. He felt that he was hurting others rather than supporting them, which made him feel guilty. The therapist noted that others were disappointing him and perhaps he was angry, but Mr. A said that he was very slow to get angry. During the exchanges with employees, his stomach was tight, as if he were waiting for someone to punch him. The therapist remarked on how Mr. A felt as though he was punching others and wondered perhaps whether his bodily experience represented a punishment. Mr. A described how he had decided not to tell his mother he was marrying his second wife, as he felt that she would be too critical and controlling. When he did tell her, she did not speak to him for several weeks. He described how difficult it was to disappoint her. The therapist suggested that he felt abandoned when he was sent away three times and believed that if he had been a better or perfect child, this would not have happened. The link between abandonment and not doing what was expected of him was explored in session 10 when Mr. A brought up another memory. At age 7, his mother served him a bowl of cereal and told him to eat it. When he did not, she left the house and locked the door behind her. He panicked, took a chair, and smashed through a window. He tried to climb out and began getting cuts from the glass. His mother, who was waiting outside, had to extricate him. Even now, Mr. A felt guilt and shame in recalling this incident. The therapist suggested that this acute sense of shame and terror was likely related to his panic. His panic attacks rapidly diminished as he increasingly understood that his symptoms represented the feelings of anger and guilt and fears of abandonment by others that he could not tolerate. A recurrence of panic that followed a visit to his mother was addressed in session 13. Mr. A’s mother had criticized him for not visiting her more often, which left him feeling undermined and guilty. In addition, the next day he had to fire an employee whom he thought of as being very much like his mother. The employee was complimentary toward him but bad-mouthed him behind his back. Mr. A was able to acknowledge some anger at his mother and the employee. The therapist noted that Mr. A’s anger likely contributed to his anxiety and guilt. The therapist continued to explore Mr. A’s unacknowledged anger in several contexts. These feelings had to be repressed in the attempt to be perfect and pleasing to others, to avoid being abandoned. Mr. A noted that one situation in which he had learned to suppress his anger was when his mother took care of the elderly man when Mr. A was in high school. He was angry at the man for his abusive behavior but, at his mother’s request, did not express the anger. He felt in part that it was a racial issue because black people (such as Mr. A and his mother), in his mother’s view, needed to submit to white men (such as the elderly man). However, Mr. A felt less troubled by racial issues at the time of his treatment. He also felt guilty because he believed that his mother had stayed at this job to afford sending him to college. Understanding his inhibitions and guilt helped him to acknowledge his frustration with his mother, employees, and his bosses.
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Phase III termination Because Mr. A had not raised the issue of upcoming termination, the therapist reminded him of the approaching end of treatment at session 16, as they entered the last phase. At first, Mr. A denied that this was of concern to him, as his panic remained diminished and he believed that he had a much better understanding of the factors contributing to it. However, over the next few sessions he recognized that he was having some anxiety about treatment ending and about whether he would be okay afterward. He asked for clarification of the policy on booster sessions. The therapist explored with him potential abandonment concerns, given his history of being repeatedly “sent away” as a child. He was able to recognize this link and that now, in contrast to when he was a child, he had a clear understanding of the basis for ending treatment and ways to reconnect should he need to. Like many patients, he was more reluctant to acknowledge anger toward the therapist but did acknowledge frustration that treatment had to end, as he found it very valuable. As Mr. A left therapy, his panic remained resolved, as did his generalized anxiety disorder, and he recognized an ongoing need to be alert to abandonment fears and angry feelings. His limit setting with his mother had improved significantly, with diminished guilt.
Conclusion PFPP has demonstrated efficacy in the treatment of panic disorder with or without agoraphobia. The approach has been expanded to treat a broader range of anxiety disorders in a revised treatment manual (PFPP-XR). Further research is necessary to determine the impact of PFPP-XR on other anxiety disorders, cluster C personality disorders, and PTSD to help identify which patients respond better to this approach in comparison with medications and CBT. In addition, further studies will be necessary to determine what treatment or combination of treatments works best for which patients over the long term. Additional efforts to identify effective components and mediators of treatment are necessary, including further exploration of the role of reflective functioning, consistency of focus on panic and anxiety symptoms and dynamics, and/or the value of addressing specific dynamics. Dr. Milrod’s work was supported in part through a Fund in the New York Community Trust established by DeWitt Wallace and a grant through the Weill Cornell Clinical Translational Science Center Grant/Protocol Number: UL1 TR000457.
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press.
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Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA, 283, 2529 2536. Brown, T. A., DiNardo, P., & Barlow, D. H. (1995). Anxiety disorders interview schedule for DSM-IV: Lifetime Version (ADISIV-L). New York: Graywinds. Busch, F., Cooper, A. M., Klerman, G. L., Shapiro, T., & Shear, M. K. (1991). Neurophysiological, cognitive-behavioral and psychoanalytic approaches to panic disorder: Toward an integration. Psychoanalytic Inquiry, 11, 316 332. Busch, F., Milrod, B. L., Singer, M., & Aronson, A. (2012). Panic-focused psychodynamic psychotherapy, EXtended Range. New York: Routledge. Busch, F., Shear, M. K., Cooper, A. M., Shapiro, T., & Leon, A. (1995). An empirical study of defense mechanisms in panic disorder. Journal of Nervous and Mental Disease, 183, 299 303. Cerny, J.A., Vermilyea, B.B., Barlow, D.H., et al. (1984) Anxiety treatment project relaxation treatment manual. Unpublished manuscript. Craske, M. G., Barlow, D. H., & Meadows, E. (2000). Master your own anxiety and panic: Therapist guide for anxiety, panic, and agoraphobia (MAP-3). San Antonio, TX: Graywind/Psychological Corporation. First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Benjamin, L. (1994). Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II), Version 2.0. New York: Biometrics Research Department, New York State Psychiatric Institute. Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in selforganization. Development and Psychopathology, 62, 880 893. Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50 55. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56 62. Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. Washington, DC: American Psychiatric Press. Milrod, B., Busch, F., Leon, A. C., Aronson, A., Roiphe, J., Rudden, M., . . . Shear, M. K. (2001). A pilot open trial of brief psychodynamic psychotherapy for panic disorder. Journal of Psychotherapy Practice and Research, 10(4), 239 245. Milrod, B., Busch, F., Leon, A. C., Shapiro, T., Aronson, A., Roiphe, J., . . . Shear, M. K. (2000). An open trial of psychodynamic psychotherapy for panic disorder: A pilot study. American Journal of Psychiatry, 157, 1878 1880. Milrod, B., Chambless, D. L., Gallop, R., Busch, F. N., Schwalberg, M., McCarthy, K. S., . . . Barber, J. P. (2016). Psychotherapies for panic disorder: A tale of two sites. Journal of Clinical Psychiatry, 77, 927 935. Milrod, B., Leon, A. C., Busch, F. N., Rudden, M., Schwalberg, M., Clarkin, J., . . . Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265 272. Rudden, M., Milrod, B., Target, M., Ackerman, S., & Graf, E. (2006). Reflective functioning in panic disorder patients: A pilot study. Journal of the American Psychoanalytic Association, 54, 1339 1343. Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., . . . Papp, L. A. (1997). Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154, 1571 1575. Shear, M. K., Cooper, A. M., Klerman, G. L., Busch, F. N., & Shapiro, T. (1993). A psychodynamic model of panic disorder. American Journal of Psychiatry, 150, 859 866.
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Sheehan, D. V. (1983). The Sheehan disability scales. The anxiety disease (p. 151) New York: Scribner. Subic-Wrana, C., Knebel, A., Beutel, M. E. (2010). The Mainz PFPP study: A RCT comparing a psychodynamic and a cognitive behavioral short-term psychotherapy for panic disorder. Panel presentation at Society for Psychotherapy Research, Asilomar, CA.
Further reading Craske, M. G., & Barlow, D. H. (1988). Cognitive-behavioral treatment of panic. In A. J. Frances, & R. E. Hales (Eds.), Review of psychiatry. Washington, DC: American Psychiatric Press.
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Fredric N. Busch1 and Barbara L. Milrod1,2,3 1 Weill Cornell Medical College, New York, NY, United States, 2New York Psychoanalytic Institute, New York, NY, United States, 3Columbia University Center for Psychoanalytic Training and Research, New York, NY, United States
Introduction Panic-focused psychodynamic psychotherapy (PFPP) was developed to elaborate core psychodynamic conflicts and meanings of symptoms associated with panic disorder and agoraphobia and to modify more open-ended psychodynamic approaches to focus on panic symptoms (Busch, Milrod, Singer, & Aronson, 2012). This treatment has been extended (Panic-focused psychodynamic psychotherapy extended range; PFPP-XR) to address a range of DSM 5 (American Psychiatric Association, 2013) anxiety disorders, cluster C personality disorders, and posttraumatic stress disorder (PTSD), with the identification of dynamisms that appear prominently in these various disorders (Busch et al., 2012). PFPP has been subjected to efficacy testing in randomized controlled trials as a 12-week, 24-session psychotherapy and has demonstrated efficacy for treatment of panic disorder with and without agoraphobia (Milrod et al., 2007; Subic-Wrana, Knebel, & Beutel, 2010). It has also been studied in comparison to cognitive-behavioral therapy and applied relaxation training (Milrod et al., 2016) and meets evidence-based medicine criteria.
A psychodynamic formulation for panic and anxiety disorders Busch, Cooper, Klerman, Shapiro, and Shear (1991), Shear, Cooper, Klerman, Busch, and Shapiro (1993), and Milrod, Busch, Cooper, and Shapiro (1997) articulated a series of dynamic psychological constellations underlying panic disorder. According to this psychodynamic formulation, a combination of genetically based vulnerabilities and significant developmental experiences contributes to psychological vulnerabilities to panic disorder onset and persistence as well as a range of anxiety disorders. Children in these circumstances feel particularly threatened by separation and develop a sense of fearful dependency on caregivers, who are experienced as (and often are in some ways) unreliable or rejecting. Normal efforts to develop autonomy create anxiety and conflict because of their link to separation Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00008-8 © 2019 Elsevier Inc. All rights reserved.
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and symbolic loss of primary attachment figures. Such strivings may well have constituted high-anxiety situations for parents in childhood because of their own separation and attachment dysregulations. The children become frightened and guilty about angry feelings and fantasies, fearing that they will disrupt or damage relationships with caregivers or parents. Defense mechanisms such as denial, reaction formation, and undoing are triggered in an unconscious effort to reduce the threat from angry feelings and fantasies and to ensure a greater sense of safety in core attachment relationships (Busch, Shear, Cooper, Shapiro, & Leon, 1995), but the potential conscious emergence of these seemingly disruptive fantasies causes persistent anxiety and guilt. In addition, mentalization, that is, the capacity to conceive of behaviors as deriving from mental states (Fonagy & Target, 1997), is disrupted in these anxious patients by avoidance of feelings and frightening experiences with caretakers. The lack of capacity to mentalize interferes with the ability to identify relevant feelings and thoughts occurring in intense attachment relationships, often contributing to conflicts being expressed in somatic form. In adulthood, perceived attachment threats cause regression and a surge of anger, anxiety, and guilt, along with a shutdown of mentalization capacity that cannot be readily identified or managed, leading ultimately to panic. The resulting panic attacks can function as punishment for angry fantasies, as a defense against anger through presenting the self as weak and damaged (often a calming fantasy for these patients), and as a plea for more regressive, childlike care from core attachment figures via appealing for help. Patients with other DSM 5 anxiety disorders have dynamic constellations that overlap in varying degrees with those typically found in patients with panic disorder. Patients with anxiety disorders are prone to viewing themselves as inadequate and ineffective, believing that another person is essential for their safety or even survival. These self-representations are triggered by fears of greater autonomy or of angry feelings, which are often perceived as threats to close attachment relationships. In addition, specific conflicts can be more characteristically prominent among patients with individual DSM 5 anxiety disorders. For example, patients with social phobia often struggle with an underlying sense of inadequacy that triggers compensatory grandiose fantasies and exhibitionistic wishes. Grandiose and exhibitionistic fantasies can create conflict and guilt and can lead to feelings of disappointment and excessive self-criticism in actual social situations, fueling anxiety. In generalized anxiety disorder, patients are often fearful of the conscious emergence of conflicted feelings and fantasies and maintain a constant state of vigilance in an effort to prevent fantasized dangers that could arise if they were to relax. Worries about finances and somatic concerns can also function as defenses against unacceptable feelings and fantasies. Chronic worrying and hypervigilance can also emerge from insecure, frightening, or unstable early relationships. Children may develop chronic fears that their close attachments with others can be easily disrupted by their own feelings and fantasies or by the fragility of others. The PFPPXR manual describes specific dynamics of various anxiety disorders in greater depths along with approaches to these disorders (Busch et al., 2012).
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Description of panic-focused psychodynamic psychotherapy extended range PFPP-XR differs from more open-ended psychodynamic psychotherapeutic approaches, focusing on the feelings, circumstances, and meanings of panic attacks, severe anxiety states, and phobic avoidance (Busch et al., 2012; Milrod et al., 1997). This information is used to identify and develop a psychodynamic formulation pertaining to the individual patient’s anxiety symptoms. Sessions initially are open-ended with the therapist exploring the themes that the patient brings up. However, anxiety symptoms and their impact are focused on consistently throughout the treatment. If the patient does not discuss his or her anxiety symptoms or related dynamics in the course of the session, the therapist eventually turns the patient’s attention to them. Seemingly unrelated emergent themes are consistently linked to anxiety symptoms and their underlying dynamics, including their emergence in the transference. This time-limited treatment requires a more rapid development of a formulation surrounding the underlying meanings of panic and anxiety than typically occurs in more traditional, open-ended psychodynamic psychotherapy. PFPP-XR is divided into three phases, although elements of each phase can occur throughout the treatment. In the first phase the therapeutic focus is on episodes of panic or severe anxiety; exploring the patient’s circumstances, feelings, and thoughts surrounding symptoms; and beginning to identify underlying fantasies and meanings of symptoms. The therapist works with the patient to demonstrate that symptoms have powerful emotional meanings and context rather than coming out of the blue; this work serves to improve reflective functioning. The patient’s developmental history is explored as it pertains to anxiety, and the therapist begins to discuss this overarching psychological context in terms of its potential relevance to symptoms. The therapist develops and presents a preliminary psychodynamic formulation about the meaning and dynamics of the patient’s anxiety or panic during this phase, usually within the first few sessions, typically involving themes and conflicts surrounding separation, anger, sexuality, and guilty self-punishment. This formulation provides a framework for further therapeutic work and will be added to and modified over the course of treatment. In the middle phase of therapy the therapist helps the patient to identify additional fantasies, conflicts, and developmental experiences and their relevance to prominent anxiety symptoms. The intensification of the transference during this phase allows the therapist to highlight core conflicts as they emerge in the relationship with the therapist. The goals are to reduce anxiety vulnerability with improved identification of anxiety precipitants, meanings, and conflicted feelings and fantasies; better tolerance of the patient’s own anger; and an enhanced ability to reflect on emotions and their meaning (reflective function) (Fonagy & Target, 1997). In the termination phase the therapist explores the patient’s mixed feelings about ending the therapy. If the patient has not addressed termination upon entering the final third of treatment, the therapist will raise the issue at that point. Conflicts and
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fears surrounding attachment and separation can be further explored as they emerge in the context of the upcoming separation from the therapist. These fears and conflicts can be articulated and can be understood and better tolerated in the context of the relationship with the therapist. Active focus on termination increases the patient’s capacity to manage separation, anger, guilt, and associated fantasies in ways that improve reflective functioning, which may be protective against reoccurrence of anxiety after therapy ends.
Studies of panic-focused psychodynamic psychotherapy In an open clinical trial conducted at Weill Cornell Medical College, 21 patients with primary DSM 4 (American Psychiatric Association, 1994) panic disorder with or without agoraphobia were treated with twice weekly, 24-session PFPP (Milrod et al., 2000, 2001). At the end of treatment, 16 of 21 patients showed remission of panic and agoraphobia, defined by multisite panic disorder study criteria (Barlow, Gorman, Shear, & Woods, 2000). Depression remitted in patients with comorbid major depression (N 5 8). Patients demonstrated substantial improvements in symptoms and psychosocial function [within-group effect size (ES) 5 2.08 in the primary outcome measure, the Panic Disorder Severity Scale (PDSS); Shear et al., 1997], which persisted at 6-month follow-up. Milrod et al. (2007) studied 49 patients with primary DSM 4 panic disorder with or without agoraphobia, diagnosed with the Anxiety Disorders Interview Schedule (Brown, DiNardo, & Barlow, 1995), who were randomized to either PFPP or applied relaxation therapy (ART) (Cerny et al., 1984). For patients receiving medication (18%) the dose and type of medication were kept constant. Patients were excluded if they were in another psychotherapy, and those entering the study could not engage in nonstudy psychotherapy during the treatment. Patients with severe agoraphobia, comorbid major depression, and personality disorder comorbidities were included, whereas patients with psychosis, bipolar disorder, and substance abuse (6 months remission necessary) were excluded. PFPP and ART were conducted twice weekly in 24 sessions. ART consisted of a three-session cognitive explanation about panic disorder (Cerny et al., 1984), progressive muscle relaxation techniques, and in vivo exposure to anxiety-inducing situations. Adherence ratings were assessed on three sessions from each treatment and indicated high adherence in both treatments. The ART group contained a higher proportion of men (47% vs 15%; two-tailed Fisher’s exact text, P 5 0.03), but otherwise, treatment groups were matched on demographic and clinical variables. No significant between-group differences were found with symptoms of anxiety and depression, as measured by the Hamilton Depression Rating Scale (Hamilton, 1960; P 5 0.07) and the Hamilton Anxiety Rating Scale (Hamilton, 1959; P 5 0.58). With response defined as a 40% decrease in the total PDSS score from baseline (Barlow et al., 2000), PFPP demonstrated a significantly higher response rate than ART (73% vs 39%; P 5 0.016). Subjects in
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the PFPP condition experienced significantly greater improvement in panic symptoms, as assessed by the PDSS (P 5 0.002), and psychosocial function, as measured by the Sheehan Disability Scale (Sheehan, 1983; P 5 0.014). PFPP was well tolerated, with a 7% (2 of 26 subjects) dropout rate. PFPP was the first psychoanalytic treatment to demonstrate efficacy for treatment of an axis I anxiety disorder (DSM 4 panic disorder and agoraphobia). In a pilot study utilizing data from the controlled trial described above, Rudden, Milrod, Target, Ackerman, and Graf (2006) studied reflective function and panicspecific reflective functioning (PSRF). PSRF was developed as a measure of the extent to which patients are aware of the link between panic and anxiety symptoms and underlying emotional content. Patients treated with PFPP demonstrated a significant improvement in PSRF from baseline to posttreatment, but those treated with ART did not. However, in this pilot study, which was underpowered, the degree of change in panic severity on the PDSS did not correlate with the degree of change in the PSRF, nor was the design appropriate to assess mechanisms. Milrod et al. (2016) conducted a randomized controlled trial of 201 patients with primary DSM 4 panic disorder with or without agoraphobia at two sites (Weill Cornell Medical College and the University of Pennsylvania) comparing PFPP, cognitive-behavioral therapy (CBT), and ART. Patients were included if they had had more than one panic attack per week in the preceding month as assessed by the ADIS IV Lifetime Version (Brown et al., 1995). Patients with active substance dependence, history of bipolar disorder or psychosis, acute suicidality, or organic mental syndrome were excluded. Patients on medication were included if doses had been stable for at least 2 months. The medication was monitored throughout the course of treatment, and ongoing psychotherapy was prohibited. Patients received 19 24 sessions over 16 weeks, lasting 45 50 minutes. CBT followed the protocol of panic control therapy (Craske, Barlow, & Meadows, 2000), modified by Chambless and Schwalberg to match the number of sessions in this study. This treatment contains (1) psychoeducation about anxiety and panic disorder; (2) identification and correction of maladaptive thoughts about anxiety and panic; (3) training in slow, diaphragmatic breathing; and (4) exposure to bodily sensations designed to mimic those of anxiety and panic (interoceptive exposure). ART was more active, with a more rigorous in vivo exposure protocol than in the Milrod et al. (2007) trial, and PFPP was employed as per the treatment described in this chapter. Response was defined as 40% reduction from the baseline PDSS score (Shear et al., 1997), the primary outcome measure. Adherence ratings were assessed by modality-specific rating scales by trained raters. Patients were found to have high comorbidity, including 80% with moderate to severe agoraphobia, 73% with more than one comorbid axis I disorder, 68% with at least one additional anxiety disorder, and 48% with axis II comorbidity on the SCID-II (First, Spitzer, Gibbon, Williams, & Benjamin, 1994). Relative to the Cornell sample, the Penn patients were found to have higher baseline severity of panic disorder on the PDSS, had less education, were younger, and were less racially and ethnically diverse. There were significant site by treatment differences in the effects of psychotherapies. Cornell patients improved at similar rates across
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all three treatments, whereas Penn patients improved significantly faster in ART and CBT than in PFPP. At treatment termination, Cornell patients responded better to PFPP and CBT compared to ART, whereas Penn patients did not show a differential response across treatments. Overall response rates across both sites were 46% for ART, 63% for CBT, and 59% for PFPP. Dropout rates were significantly higher for ART, which did not vary by site, and patients who were most symptomatic dropped out of ART significantly more (69% in ART, 26% in PFPP, 24% in CBT, P 5 0.013). Medication use, which was sevenfold higher at the Penn site, did not account for all of the differences in treatment effect. The underperformance of PFPP at Penn might reflect its novelty for the psychodynamic therapists there or might reflect the influence of other process factors.
PFPP-XR case example Mr. A was a 40-year-old man who directed a division of computer programmers at a tech company, was in his second marriage, and had a 5-year-old daughter from his first marriage. He had his most recent panic attack 2 days before his 40th birthday, 6 weeks before he entered treatment. He was diagnosed with panic disorder with agoraphobia, social phobia, and generalized anxiety disorder on the ADIS-IVL (Brown et al., 1995) and was randomized to a 24-session, 12-week treatment with PFPP as part of the psychotherapies for panic disorder study.
Phase I In starting the treatment, the therapist explored the circumstances and feelings surrounding panic onset while attending to the meaning of symptoms. Mr. A reported that he had recently found his work extremely stressful. He acknowledged wanting to be the perfect boss and had struggled with expectations from the company that he reprimand or fire several of his employees. The necessity of doing so had increased because of financial cutbacks in his division, which he attributed to competition from other companies and poor management of his own company. He had hoped to turn around some of these problems when he had become head of his division, but it had not gone as he had expected. He felt responsible and guilty about his inability to fix the problems even as he acknowledged that he had a limited ability to control the situation. He denied being angry at the company managers, despite blaming them for many of the difficulties in his job. On the day of his panic attack, he had to fire someone and had a surge of guilt, feeling that he had let the employee down. He described it as the most stressful day in his life. When he experienced the onset of numbness and paresthesias in his arms and legs along with twitching and severe anxiety, he thought he was having a stroke and went to the emergency department, where he was medically cleared and told that he was likely having a panic attack. Mr. A’s first panic attack had occurred 4 years before, when he was at his prior job, which was also very stressful. He was getting divorced after finding out that
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his then-wife was involved in an affair with a man whom she eventually married. Mr. A reported that an additional stress in the period between his past and recent panic episodes had been tensions with his ex-wife regarding custody and financial arrangements for their daughter. His ex-wife recurrently threatened to prevent Mr. A’s visits with his daughter, sometimes refusing to let the child go. On one of these occasions, about 2 years previously, his ex-wife called the police after a particularly severe argument. Mr. A was arrested and charged with assault, although he denied that this had occurred. He was eventually cleared of all charges but had to go through a lengthy trial that led to the loss of his prior job. Since that time, he had remained very tense and wary when seeing his ex-wife, although their conflicts about visits had not been as severe. In addition to his struggles at work and with his ex-wife, Mr. A reported that he was grappling with long-standing demands from his mother that he pay more attention to her. In this context the therapist explored the patient’s developmental history in greater depth. Mr. A reported that his early environment was repeatedly disrupted. His parents did not believe that the metropolitan area that he was growing up in was safe, so they sent him to live with his grandparents in a Caribbean country from ages 4 to 8. He returned to live with his parents but felt lost and confused in his third-grade class in school. He then was sent to live with an aunt and uncle in another metropolitan area for 2 years, where his academic work improved. His parents divorced when he was 14, and he was sent to military school from 8th to 11th grade. When he was back home, he felt pressure to take care of his mother, who remained embittered about her divorce, which was precipitated in part by his father having an affair. Mr. A felt that he had become his mother’s counselor and needed to be the man of the family. He believed that he had to hold in his own thoughts and feelings to protect her. Related problems occurred when his mother, a nurse, took care of an older man who was verbally abusive to her. Mr. A and his mother moved into a room in the man’s house for a period. Mr. A was exposed to the verbal abuse but was not allowed to respond. He reported that he had learned early on as part of his culture that he was supposed to respect authority and not complain. Mr. A was able to fairly readily link his panic attacks to issues related to his mother. His mother criticized his ex-wife for not having his mother more involved in their lives and was now very critical of Mr. A for trying to set limits on her involvement with his new wife. It emerged that Mr. A believed that his mother was self-centered and maintained a victim stance. She had had an accident 10 years previously in which her leg was injured, and she had successfully pursued a legal case. However, he believed that afterward, his mother made little effort to improve her situation, remaining homebound, complaining about her fate, and making demands on Mr. A to spend time with her. During the fifth session, the therapist offered a preliminary formulation to Mr. A regarding his panic attacks and generalized anxiety. The therapist suggested that Mr. A’s wish to please others and need for perfection had developed in the context of efforts to appease his parents after he felt abandoned as a child when sent to live with relatives. The need to be perfect, however, placed undue pressure on him,
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particularly in the context of the problems in his current life, including the demands of his job, mother, and ex-wife. Complicating his abandonment fears, Mr. A struggled with angry feelings toward the managers at work, his mother, and his ex-wife, but he typically denied being angry, believing that such feelings did not show respect for others. The therapist suggested that Mr. A was very frightened of his anger and that his panic attacks stemmed from fears of his anger and being abandoned. Mr. A reported that his father was demanding and that contact with him was limited. An English teacher, Mr. A’s father was very frustrated with his son’s difficulties in spelling and writing. Mr. A recalled a terrifying incident in which his father chased him around a table when he was 8 years old when he misspelled a word. His father grabbed him, opened the door, and was going to throw him out when his mother intervened. He had had a rapprochement with his father in his early 20s after his father attended a therapy course recommended by Mr. A. Mr. A described his first wife as “feisty” and as having said that she was frustrated that he would not make more efforts to defend himself. Marital stresses were created by struggles for control with his mother, who demanded his time and attention. His ex-wife was angry that he did not set better limits with his mother. Mr. A stated that he was attracted to women who had overcome adversity. His second wife, whom he had married 2 years previously, had lost her mother and was estranged from her father. He described her as very “up front” and said the relationship was going well. Mr. A worked to set limits with his mother, but he believed that his mother recurrently attempted to punish him for this by being withholding and critical, triggering intense guilt. On Mother’s Day, his mother had adopted an “oh don’t bother with me” attitude when Mr. A said that he did not have time to take her out to a restaurant, behavior that he experienced as guilt inducing, passive aggressive, and manipulative. He felt that he was disappointing her by not spending more time with her.
Phase II In phase II the therapist further explored the dynamics surrounding Mr. A’s panic and difficulties with relationships. Mr. A described how at some point, he learned that the best way to be liked was to be “perfect,” including being the perfect son and perfect boss, always nice to others. He made efforts to please people, with the idea that then they would like him. In this context, the therapist and Mr. A recognized that his need to discipline people at work and set boundaries with his mother created intense anxiety. Mr. A talked about his ongoing struggles at work, and the therapist focused on what Mr. A was experiencing. He felt pressured by his bosses to do things he did not agree with, which he described as “dog eat dog.” The manager who had made Mr. A head of his division left the company, and the new leader did not have the same ethics. Mr. A blamed himself for the problems in his division, and the therapist pointed out that he had been placed in a very difficult position.
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The most difficult interactions with employees occurred when Mr. A had to critique, reprimand, or increase pressure on them. He felt that he was hurting others rather than supporting them, which made him feel guilty. The therapist noted that others were disappointing him and perhaps he was angry, but Mr. A said that he was very slow to get angry. During the exchanges with employees, his stomach was tight, as if he were waiting for someone to punch him. The therapist remarked on how Mr. A felt as though he was punching others and wondered perhaps whether his bodily experience represented a punishment. Mr. A described how he had decided not to tell his mother he was marrying his second wife, as he felt that she would be too critical and controlling. When he did tell her, she did not speak to him for several weeks. He described how difficult it was to disappoint her. The therapist suggested that he felt abandoned when he was sent away three times and believed that if he had been a better or perfect child, this would not have happened. The link between abandonment and not doing what was expected of him was explored in session 10 when Mr. A brought up another memory. At age 7, his mother served him a bowl of cereal and told him to eat it. When he did not, she left the house and locked the door behind her. He panicked, took a chair, and smashed through a window. He tried to climb out and began getting cuts from the glass. His mother, who was waiting outside, had to extricate him. Even now, Mr. A felt guilt and shame in recalling this incident. The therapist suggested that this acute sense of shame and terror was likely related to his panic. His panic attacks rapidly diminished as he increasingly understood that his symptoms represented the feelings of anger and guilt and fears of abandonment by others that he could not tolerate. A recurrence of panic that followed a visit to his mother was addressed in session 13. Mr. A’s mother had criticized him for not visiting her more often, which left him feeling undermined and guilty. In addition, the next day he had to fire an employee whom he thought of as being very much like his mother. The employee was complimentary toward him but bad-mouthed him behind his back. Mr. A was able to acknowledge some anger at his mother and the employee. The therapist noted that Mr. A’s anger likely contributed to his anxiety and guilt. The therapist continued to explore Mr. A’s unacknowledged anger in several contexts. These feelings had to be repressed in the attempt to be perfect and pleasing to others, to avoid being abandoned. Mr. A noted that one situation in which he had learned to suppress his anger was when his mother took care of the elderly man when Mr. A was in high school. He was angry at the man for his abusive behavior but, at his mother’s request, did not express the anger. He felt in part that it was a racial issue because black people (such as Mr. A and his mother), in his mother’s view, needed to submit to white men (such as the elderly man). However, Mr. A felt less troubled by racial issues at the time of his treatment. He also felt guilty because he believed that his mother had stayed at this job to afford sending him to college. Understanding his inhibitions and guilt helped him to acknowledge his frustration with his mother, employees, and his bosses.
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Phase III termination Because Mr. A had not raised the issue of upcoming termination, the therapist reminded him of the approaching end of treatment at session 16, as they entered the last phase. At first, Mr. A denied that this was of concern to him, as his panic remained diminished and he believed that he had a much better understanding of the factors contributing to it. However, over the next few sessions he recognized that he was having some anxiety about treatment ending and about whether he would be okay afterward. He asked for clarification of the policy on booster sessions. The therapist explored with him potential abandonment concerns, given his history of being repeatedly “sent away” as a child. He was able to recognize this link and that now, in contrast to when he was a child, he had a clear understanding of the basis for ending treatment and ways to reconnect should he need to. Like many patients, he was more reluctant to acknowledge anger toward the therapist but did acknowledge frustration that treatment had to end, as he found it very valuable. As Mr. A left therapy, his panic remained resolved, as did his generalized anxiety disorder, and he recognized an ongoing need to be alert to abandonment fears and angry feelings. His limit setting with his mother had improved significantly, with diminished guilt.
Conclusion PFPP has demonstrated efficacy in the treatment of panic disorder with or without agoraphobia. The approach has been expanded to treat a broader range of anxiety disorders in a revised treatment manual (PFPP-XR). Further research is necessary to determine the impact of PFPP-XR on other anxiety disorders, cluster C personality disorders, and PTSD to help identify which patients respond better to this approach in comparison with medications and CBT. In addition, further studies will be necessary to determine what treatment or combination of treatments works best for which patients over the long term. Additional efforts to identify effective components and mediators of treatment are necessary, including further exploration of the role of reflective functioning, consistency of focus on panic and anxiety symptoms and dynamics, and/or the value of addressing specific dynamics. Dr. Milrod’s work was supported in part through a Fund in the New York Community Trust established by DeWitt Wallace and a grant through the Weill Cornell Clinical Translational Science Center Grant/Protocol Number: UL1 TR000457.
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press.
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Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA, 283, 2529 2536. Brown, T. A., DiNardo, P., & Barlow, D. H. (1995). Anxiety disorders interview schedule for DSM-IV: Lifetime Version (ADISIV-L). New York: Graywinds. Busch, F., Cooper, A. M., Klerman, G. L., Shapiro, T., & Shear, M. K. (1991). Neurophysiological, cognitive-behavioral and psychoanalytic approaches to panic disorder: Toward an integration. Psychoanalytic Inquiry, 11, 316 332. Busch, F., Milrod, B. L., Singer, M., & Aronson, A. (2012). Panic-focused psychodynamic psychotherapy, EXtended Range. New York: Routledge. Busch, F., Shear, M. K., Cooper, A. M., Shapiro, T., & Leon, A. (1995). An empirical study of defense mechanisms in panic disorder. Journal of Nervous and Mental Disease, 183, 299 303. Cerny, J.A., Vermilyea, B.B., Barlow, D.H., et al. (1984) Anxiety treatment project relaxation treatment manual. Unpublished manuscript. Craske, M. G., Barlow, D. H., & Meadows, E. (2000). Master your own anxiety and panic: Therapist guide for anxiety, panic, and agoraphobia (MAP-3). San Antonio, TX: Graywind/Psychological Corporation. First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Benjamin, L. (1994). Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II), Version 2.0. New York: Biometrics Research Department, New York State Psychiatric Institute. Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in selforganization. Development and Psychopathology, 62, 880 893. Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50 55. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56 62. Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. Washington, DC: American Psychiatric Press. Milrod, B., Busch, F., Leon, A. C., Aronson, A., Roiphe, J., Rudden, M., . . . Shear, M. K. (2001). A pilot open trial of brief psychodynamic psychotherapy for panic disorder. Journal of Psychotherapy Practice and Research, 10(4), 239 245. Milrod, B., Busch, F., Leon, A. C., Shapiro, T., Aronson, A., Roiphe, J., . . . Shear, M. K. (2000). An open trial of psychodynamic psychotherapy for panic disorder: A pilot study. American Journal of Psychiatry, 157, 1878 1880. Milrod, B., Chambless, D. L., Gallop, R., Busch, F. N., Schwalberg, M., McCarthy, K. S., . . . Barber, J. P. (2016). Psychotherapies for panic disorder: A tale of two sites. Journal of Clinical Psychiatry, 77, 927 935. Milrod, B., Leon, A. C., Busch, F. N., Rudden, M., Schwalberg, M., Clarkin, J., . . . Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265 272. Rudden, M., Milrod, B., Target, M., Ackerman, S., & Graf, E. (2006). Reflective functioning in panic disorder patients: A pilot study. Journal of the American Psychoanalytic Association, 54, 1339 1343. Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., . . . Papp, L. A. (1997). Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154, 1571 1575. Shear, M. K., Cooper, A. M., Klerman, G. L., Busch, F. N., & Shapiro, T. (1993). A psychodynamic model of panic disorder. American Journal of Psychiatry, 150, 859 866.
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Sheehan, D. V. (1983). The Sheehan disability scales. The anxiety disease (p. 151) New York: Scribner. Subic-Wrana, C., Knebel, A., Beutel, M. E. (2010). The Mainz PFPP study: A RCT comparing a psychodynamic and a cognitive behavioral short-term psychotherapy for panic disorder. Panel presentation at Society for Psychotherapy Research, Asilomar, CA.
Further reading Craske, M. G., & Barlow, D. H. (1988). Cognitive-behavioral treatment of panic. In A. J. Frances, & R. E. Hales (Eds.), Review of psychiatry. Washington, DC: American Psychiatric Press.