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Psychodynamic Approaches to the Adolescent With Panic Disorder
BOOK REVIEWS
In addition, the book elaborates on the acquisition of executive skills in special populations of children, such as those with ADHD, the pervasive developmental disorder spectrum, sleep disorders, and sleep deprivation. The first two chapters give an overview of the developmental sequence of the acquisition of executive skills, its components, and the assessment of executive skills and include informal and formal assessments and behavior checklists as tools. The chapters provide case examples that tie in with the different assessment tools in a pragmatic way. The importance of linking assessment with interventions and the use of data obtained to formulate a detailed treatment plan are emphasized by this text. Interventions to promote executive skill development are also described in great detail. The current emphasis on the biopsychosocial conceptualization of any clinical syndrome poses a challenge to all educators in mental health in that there are few models to provide trainees with a practical and effective framework that emphasizes this approach. In that regard, the text provides the reader with a prototype using the biopsychosocial approach toward describing common clinical problems encountered in ADHD and comorbid syndromes, along with the use of data to formulate a well thought-through intervention plan. An emphasis on achieving success by breaking down these steps into simple, understandable concepts can definitely be helpful for educators. Behavioral techniques are laid out in concrete and comprehensible terms. The authors provide vignettes to illustrate the model they propose, which makes it relevant to the clinician in a user-friendly manner. Coaching for individuals with ADHD who have executive skill deficits, akin to the mentoring process suggested by other leaders in the field such as Barkley, is suggested as an effective intervention for students in the classroom. The book concludes by pointing out numerous practical interventions that use coaching as the guiding principle to deal with common problems seen in the classroom that arise out of the executive skill deficits in ADHD. These interventions can be generalized to an entire mainstream classroom in addition to special populations of children. This book provides a useful understanding and a practical guide to interventions that may aid in executive skill promotion within a classroom setting. The authors have delivered what they set out to do: provide a userfriendly text to professionals who interact with children in a school setting. Yet the impact of the psychosocial factors and family dynamics that are central to clinical interventions from the clinician’s viewpoint fall beyond the purview of this text. Therefore, we would recommend that, rather than clinicians, school guidance counselors, teachers, and parents acquire the book; clinicians should use it as an adjunct to gain a sharper understanding of what their
496
colleagues within the education system could do to help children with executive skill deficits actualize their potential. Radhika Sriram, M.D. Bela Sood, M.D. Division of Child Psychiatry Virginia Commonwealth University School of Medicine Richmond DOI: 10.1097/01.chi.0000199023.45958.82
Disclosure: The authors have no financial relationships to disclose.
Psychodynamic Approaches to the Adolescent With Panic Disorder. By Barbara L. Milrod, Fredric N. Busch, and Theodore Shapiro. Malabar, FL: Krieger Publishing Company, 2004, 140 pp., $23.50 (hardcover). Can psychodynamic psychotherapy be manual based? For many years psychodynamic therapists have denied this possibility. Without treatment manuals, efficacy studies have been impossible to do. Without efficacy studies, psychodynamic psychotherapy struggles to maintain a place in the therapeutic lineup in the era of evidence-based practice. The authors of Psychodynamic Approaches to the Adolescent With Panic Disorder demonstrate that it is not impossible to write a manual for a psychodynamic psychotherapy. They have taken their 1997 Manual of PanicFocused Psychodynamic Psychotherapy (coauthored by Arnold Cooper) and made adaptations for the treatment of adolescents. Because they were interested in preparing a manual-based treatment, the authors focused on a single DSM-IV diagnosis and the psychodynamic understanding of that specific condition. Rarely can readers access psychodynamic approaches by DSM diagnosis, a source of frustration to many child and adolescent psychiatrists. Panic-focused psychodynamic psychotherapy for adolescents (PFPP-A) is organized in three phases: treatment of acute panic, treatment of panic vulnerability, and termination. In the initial phase, the meaning of the panic symptoms for the particular patient and family are explored and assessed in relationship to the core dynamics of panic disorder: anxieties over independence and separation, anger management, and sexual excitement. Phase two seeks to lessen vulnerability to panic, working through the core dynamics by addressing them explicitly as they appear in the transference. PFPP-A is designed as a 12-week, 24-session treatment. This time limitation is hypothesized to heighten the patient’s
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:4, APRIL 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BOOK REVIEWS
experience in the transference of the core themes of separation and anger. The authors advise devoting a minimum of a third of sessions to addressing the patient’s reaction to termination. Unlike their work with adults, with whom they adhered strictly to the brief treatment model, with some of their adolescent patients whose panic symptoms had remitted, treatment continued to address character pathology that was interfering with the adolescent’s development. In the authors’ earlier study of adults, process-outcome analysis revealed that addressing defenses in the middle phase of the treatment reduced panic symptoms at outcome. The authors propose that, although similar to adults in using reaction formation, somatization, and undoing, adolescents are more likely than adults to deploy externalizing and counterphobic defenses. The therapist treating the adolescent patient is challenged to translate the defensive meaning of behaviors and actions into effectively meaningful verbal equivalents. Milrod and colleagues devote a brief chapter to working with the adolescent’s family. Here they recommend at least one meeting with the parents and adolescent together to secure parental cooperation, to reduce the likelihood of frequent calls from anxious parents, and to allow the adolescent to see the therapist as an ally who is not unaware of the realities of the adolescent’s day-to-day life. Rich clinical vignettes, which bring alive the patient, the therapist, and the technique, are a strength of this volume. The sections ‘‘Acting Out’’ and ‘‘Drugs and Sex’’ will help experienced clinicians, as well as trainees, to hone the fine points of nonjudgmental confrontation that is a core skill for psychodynamic psychotherapists working with adolescents. In a lively dialogue between patient and therapist, the authors ably demonstrate how, in the therapeutic exchange with an adolescent girl threatening to use cocaine, the therapist’s dynamic understanding and ability to talk comfortably about the transference brought the adolescent to understand her risk-taking behavior and voluntarily step back from the brink. The use of psychopharmacology and cognitive-behavioral treatment for panic disorder both as primary treatments and as adjuncts to PPFP-A are mentioned, but this book is not a comprehensive guide to the treatment of panic disorder. Because of its focus on panic disorder, it cannot be considered an all-purpose primer on psychodynamic treatment of adolescents. Nevertheless, it may be a valuable tool in teaching psychodynamic psychotherapy to the novice therapist. The authors’ multiple discussions of adolescent development and the unique issues that adolescents bring to therapy are a strength of the volume. They explain how the developmental tasks of adolescence may precipitate panic disorder. The most glaring weaknesses of the book may be caused by its having multiple authors. The introduction is vague and elements that should be included in the introduction are scattered throughout the book. The intention to provide a
J. AM . ACAD. CH ILD ADOLESC. PSYCH IAT RY, 45:4, APRIL 2006
manual is not explicitly mentioned until Chapter 6. The absence of an index is annoying. Despite these flaws, the writing is succinct and engaging, making the whole a quick and easy read. The book will be helpful for clinicians with a general interest in psychodynamic therapy, those interested in the treatment strategies for adolescent panic disorder, experienced clinicians who are interested in refreshing their clinical acumen with challenging adolescents and with panic disorder, and for individuals interested in conducting clinical studies looking at the outcome of a standardized psychodynamic treatment. Through its vignettes and discussion, Psychodynamic Approaches makes the goals of psychodynamic therapy of adolescents with panic disorder clear and attainable. Christopher Bir, M.D. Gonzalo Laje, M.D. Rachel Z. Ritvo, M.D. Department of Psychiatry and Behavioral Sciences Children’s National Medical Center Washington, DC DOI: 10.1097/01.chi.0000199024.84075.63
Disclosure: The authors have no financial relationships to disclose.
Phobic and Anxiety Disorders in Children and Adolescents: A Clinician’s Guide to Effective Psychosocial and Pharmacologic Interventions. Edited by Thomas H. Ollendick and John S. March. New York: Oxford University Press, 2004, 592 pp., $69.50 (hardcover). Anxiety Disorders in Children and Adolescents, Second Edition. Edited by Tracy L. Morris and John S. March. New York: The Guilford Press, 2004, 398 pp., $46.00 (hardcover). Anxiety disorders have repeatedly been demonstrated to be among the most prevalent psychiatric disorders in childhood. The distress experienced by the affected youth often interferes with family life, peer relationships, and academic achievement. These disorders have high comorbidity, and many are linked with adult psychopathology. Any one of these aspects alone is a compelling reason for clinicians to be skilled in the diagnosis and treatment of anxiety disorders in children and adolescents. Considered together, they make it imperative. Many researchers have answered this ‘‘call to arms’’ during the past 10 to 15 years, rapidly expanding our knowledge of the development, comorbidity, evaluation, and treatment of these disorders. This review describes two texts addressing this expanding field. Each book is evidence based and carefully organized to help guide the clinician to the most effective tools for evaluation and treatment.
497
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
In addition, the book elaborates on the acquisition of executive skills in special populations of children, such as those with ADHD, the pervasive developmental disorder spectrum, sleep disorders, and sleep deprivation. The first two chapters give an overview of the developmental sequence of the acquisition of executive skills, its components, and the assessment of executive skills and include informal and formal assessments and behavior checklists as tools. The chapters provide case examples that tie in with the different assessment tools in a pragmatic way. The importance of linking assessment with interventions and the use of data obtained to formulate a detailed treatment plan are emphasized by this text. Interventions to promote executive skill development are also described in great detail. The current emphasis on the biopsychosocial conceptualization of any clinical syndrome poses a challenge to all educators in mental health in that there are few models to provide trainees with a practical and effective framework that emphasizes this approach. In that regard, the text provides the reader with a prototype using the biopsychosocial approach toward describing common clinical problems encountered in ADHD and comorbid syndromes, along with the use of data to formulate a well thought-through intervention plan. An emphasis on achieving success by breaking down these steps into simple, understandable concepts can definitely be helpful for educators. Behavioral techniques are laid out in concrete and comprehensible terms. The authors provide vignettes to illustrate the model they propose, which makes it relevant to the clinician in a user-friendly manner. Coaching for individuals with ADHD who have executive skill deficits, akin to the mentoring process suggested by other leaders in the field such as Barkley, is suggested as an effective intervention for students in the classroom. The book concludes by pointing out numerous practical interventions that use coaching as the guiding principle to deal with common problems seen in the classroom that arise out of the executive skill deficits in ADHD. These interventions can be generalized to an entire mainstream classroom in addition to special populations of children. This book provides a useful understanding and a practical guide to interventions that may aid in executive skill promotion within a classroom setting. The authors have delivered what they set out to do: provide a userfriendly text to professionals who interact with children in a school setting. Yet the impact of the psychosocial factors and family dynamics that are central to clinical interventions from the clinician’s viewpoint fall beyond the purview of this text. Therefore, we would recommend that, rather than clinicians, school guidance counselors, teachers, and parents acquire the book; clinicians should use it as an adjunct to gain a sharper understanding of what their
496
colleagues within the education system could do to help children with executive skill deficits actualize their potential. Radhika Sriram, M.D. Bela Sood, M.D. Division of Child Psychiatry Virginia Commonwealth University School of Medicine Richmond DOI: 10.1097/01.chi.0000199023.45958.82
Disclosure: The authors have no financial relationships to disclose.
Psychodynamic Approaches to the Adolescent With Panic Disorder. By Barbara L. Milrod, Fredric N. Busch, and Theodore Shapiro. Malabar, FL: Krieger Publishing Company, 2004, 140 pp., $23.50 (hardcover). Can psychodynamic psychotherapy be manual based? For many years psychodynamic therapists have denied this possibility. Without treatment manuals, efficacy studies have been impossible to do. Without efficacy studies, psychodynamic psychotherapy struggles to maintain a place in the therapeutic lineup in the era of evidence-based practice. The authors of Psychodynamic Approaches to the Adolescent With Panic Disorder demonstrate that it is not impossible to write a manual for a psychodynamic psychotherapy. They have taken their 1997 Manual of PanicFocused Psychodynamic Psychotherapy (coauthored by Arnold Cooper) and made adaptations for the treatment of adolescents. Because they were interested in preparing a manual-based treatment, the authors focused on a single DSM-IV diagnosis and the psychodynamic understanding of that specific condition. Rarely can readers access psychodynamic approaches by DSM diagnosis, a source of frustration to many child and adolescent psychiatrists. Panic-focused psychodynamic psychotherapy for adolescents (PFPP-A) is organized in three phases: treatment of acute panic, treatment of panic vulnerability, and termination. In the initial phase, the meaning of the panic symptoms for the particular patient and family are explored and assessed in relationship to the core dynamics of panic disorder: anxieties over independence and separation, anger management, and sexual excitement. Phase two seeks to lessen vulnerability to panic, working through the core dynamics by addressing them explicitly as they appear in the transference. PFPP-A is designed as a 12-week, 24-session treatment. This time limitation is hypothesized to heighten the patient’s
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 45:4, APRIL 2006
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BOOK REVIEWS
experience in the transference of the core themes of separation and anger. The authors advise devoting a minimum of a third of sessions to addressing the patient’s reaction to termination. Unlike their work with adults, with whom they adhered strictly to the brief treatment model, with some of their adolescent patients whose panic symptoms had remitted, treatment continued to address character pathology that was interfering with the adolescent’s development. In the authors’ earlier study of adults, process-outcome analysis revealed that addressing defenses in the middle phase of the treatment reduced panic symptoms at outcome. The authors propose that, although similar to adults in using reaction formation, somatization, and undoing, adolescents are more likely than adults to deploy externalizing and counterphobic defenses. The therapist treating the adolescent patient is challenged to translate the defensive meaning of behaviors and actions into effectively meaningful verbal equivalents. Milrod and colleagues devote a brief chapter to working with the adolescent’s family. Here they recommend at least one meeting with the parents and adolescent together to secure parental cooperation, to reduce the likelihood of frequent calls from anxious parents, and to allow the adolescent to see the therapist as an ally who is not unaware of the realities of the adolescent’s day-to-day life. Rich clinical vignettes, which bring alive the patient, the therapist, and the technique, are a strength of this volume. The sections ‘‘Acting Out’’ and ‘‘Drugs and Sex’’ will help experienced clinicians, as well as trainees, to hone the fine points of nonjudgmental confrontation that is a core skill for psychodynamic psychotherapists working with adolescents. In a lively dialogue between patient and therapist, the authors ably demonstrate how, in the therapeutic exchange with an adolescent girl threatening to use cocaine, the therapist’s dynamic understanding and ability to talk comfortably about the transference brought the adolescent to understand her risk-taking behavior and voluntarily step back from the brink. The use of psychopharmacology and cognitive-behavioral treatment for panic disorder both as primary treatments and as adjuncts to PPFP-A are mentioned, but this book is not a comprehensive guide to the treatment of panic disorder. Because of its focus on panic disorder, it cannot be considered an all-purpose primer on psychodynamic treatment of adolescents. Nevertheless, it may be a valuable tool in teaching psychodynamic psychotherapy to the novice therapist. The authors’ multiple discussions of adolescent development and the unique issues that adolescents bring to therapy are a strength of the volume. They explain how the developmental tasks of adolescence may precipitate panic disorder. The most glaring weaknesses of the book may be caused by its having multiple authors. The introduction is vague and elements that should be included in the introduction are scattered throughout the book. The intention to provide a
J. AM . ACAD. CH ILD ADOLESC. PSYCH IAT RY, 45:4, APRIL 2006
manual is not explicitly mentioned until Chapter 6. The absence of an index is annoying. Despite these flaws, the writing is succinct and engaging, making the whole a quick and easy read. The book will be helpful for clinicians with a general interest in psychodynamic therapy, those interested in the treatment strategies for adolescent panic disorder, experienced clinicians who are interested in refreshing their clinical acumen with challenging adolescents and with panic disorder, and for individuals interested in conducting clinical studies looking at the outcome of a standardized psychodynamic treatment. Through its vignettes and discussion, Psychodynamic Approaches makes the goals of psychodynamic therapy of adolescents with panic disorder clear and attainable. Christopher Bir, M.D. Gonzalo Laje, M.D. Rachel Z. Ritvo, M.D. Department of Psychiatry and Behavioral Sciences Children’s National Medical Center Washington, DC DOI: 10.1097/01.chi.0000199024.84075.63
Disclosure: The authors have no financial relationships to disclose.
Phobic and Anxiety Disorders in Children and Adolescents: A Clinician’s Guide to Effective Psychosocial and Pharmacologic Interventions. Edited by Thomas H. Ollendick and John S. March. New York: Oxford University Press, 2004, 592 pp., $69.50 (hardcover). Anxiety Disorders in Children and Adolescents, Second Edition. Edited by Tracy L. Morris and John S. March. New York: The Guilford Press, 2004, 398 pp., $46.00 (hardcover). Anxiety disorders have repeatedly been demonstrated to be among the most prevalent psychiatric disorders in childhood. The distress experienced by the affected youth often interferes with family life, peer relationships, and academic achievement. These disorders have high comorbidity, and many are linked with adult psychopathology. Any one of these aspects alone is a compelling reason for clinicians to be skilled in the diagnosis and treatment of anxiety disorders in children and adolescents. Considered together, they make it imperative. Many researchers have answered this ‘‘call to arms’’ during the past 10 to 15 years, rapidly expanding our knowledge of the development, comorbidity, evaluation, and treatment of these disorders. This review describes two texts addressing this expanding field. Each book is evidence based and carefully organized to help guide the clinician to the most effective tools for evaluation and treatment.
497
Copyright @ 2006 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.