Panic DO and Psychodynamic Therapy

[maranatha]

I, for one, have always been a little skeptical of psychodynamic therapy b/c of a lack of evidence to support its use. Here is an interesting article that came out this month:

Am j Psychiatry 2007; 164:265-272

"OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Des- pite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors’ knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18–55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder."

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[whopper]

Interesting post but it drums up several questions.

First, it appears this was not compared to a control group. Any psychotherapy can have some benefits, even if conducted by someone who has no knowledge of how to do psychotherapy. Just having someone to talk to may have yielded the benefit.

2nd--psychodynamic therapy is a highly variable therapy model, much more so than other forms of psychotherapy.

I'm not trying to refute the results, just discuss and think about them critically.

 

[nortomaso]

?

There certainly was a control group.
Psychodynamic psychotherapy was compared to an active comparator: I believe it was relaxation therapy. The time spent with a therapist was equal in the two groups.

The problem is that relaxation therapy has been shown to be inferior to CBT for PD; so not choosing CBT as a comparator was a little wimpy on the part of the investigators. Still, this was a good start. Hopefully, we'll see more trials like this and psychodynamic psychotherapy will be eventually held to the same standards of evidence as other types of treatament.

 

[meelu]

Interesting results. As a beginning therapist, I have begun to see some progress in my psychotherapy patients.
However, I would not have thought that efficacy would be shown after only 3 months of twice weekly psychodynamic training, especially for panic disorder- in my limited experience so far, it seems that its taken about 6 months *once a week though* of therapy for patients to begin developing resistance and transference, and it seems like its only now that we're beginning to explore some of the issues brought up. Do they detail what exactly they consider "panic disorder focused psychodynamic psychotherapy"? Better yet, I should take a look at this article in full I suppose.
Thanks for the post.

 

[50960]

There is no reason why we should think psychodynamic tx would help panic disorder. It makes no sense psychologically, neurologically etc...

 

[Solideliquid]

There is no reason why we should think psychodynamic tx would help panic disorder. It makes no sense psychologically, neurologically etc...

It appears that a certain number of study participants did get better with psychotherapy. If psychotherapy (over time) seems to have as much impact on mood disorders as do the pharmacologic agents, why wouldn't it be helpful for people with anxiety disorders?

Couldn't you apply the above quote to mood disorders as well (if that's your thinking) ?

 

[50960]

And SSRI's are only slightly better than placebo. Placebo is strong, people who feel they understand themselves better will report they are better even if they are not. Panic disorder is a heavily biologically based/derived disorder that requires appropriate tx's. Most people who say they have "panic attacks" do not have panic disorder.

 

[Chewbacca Jung]

And SSRI's are only slightly better than placebo. Placebo is strong, people who feel they understand themselves better will report they are better even if they are not. Panic disorder is a heavily biologically based/derived disorder that requires appropriate tx's. Most people who say they have "panic attacks" do not have panic disorder.

Logic is a bit fuzzy. I just want to give an example how the (proposed) pathophysiology of something may have nothing or little to do directly with therapy.

We all know that asthma is an immune mediated process. Yet the first line treatment for asthma is albuterol. How can something that works on the sympathetic nervous system possibly alleviate a reactive immune disease? The answer-- its complicated. By drawing lines between the immune system and the nervous system we limit our ability to understand the whole process of asthma. And, by drawing a line between the neurobiological and the psychologic it inhibits your ability to fully understand either of them and the role they play in panic d/o, and any other disorder.

A "maily biological based d/o" is an inane concept as grounds for argument against psychotherapy. For one, any amount of non-biologicalness demonstrates a role for other modalities to intervene-- and even if it were possible for psychological factors to not have any role at all in the development of panic d/o, psychotherapy may also still have a role as the above example demonstrates (possibly compensatory, or other mechanism...)

The only way to determine the efficacy of psychotherapy in a given d/o is through a sufficiently powered RCT. This study seems to show an effect at only 3 months-- and it seems that this is even supprising given meelu's reaction that you may not expect to see differences in 6 months of more intensive training. That the beauty of EBM. (the dark side of EBM is another story...)

 

[50960]

In no way was I trying to make the old mind-body split, and I fully realize the the mind aspect of even heavily biologically based psychopathology. I was trying to make a point by being extreme. Your example is a bit different because in that case the albuterol is treating the expressed sx of the disease, rather than the disease itself. That is useful to a degree of course. However, as you know SSRIs have been shown to actually treat the core malfunctions of the disease itself in the case of panic d/o, PTSD etc..., as well as the sx's. CBT, and more directed behavioral tx's are probably doing the same thing, but psychodynamic tx is much more likely to be the albuterol, thus treating only the sx's.

 

[LM02]

?

There certainly was a control group.
Psychodynamic psychotherapy was compared to an active comparator: I believe it was relaxation therapy. The time spent with a therapist was equal in the two groups.

The problem is that relaxation therapy has been shown to be inferior to CBT for PD; so not choosing CBT as a comparator was a little wimpy on the part of the investigators. Still, this was a good start. Hopefully, we'll see more trials like this and psychodynamic psychotherapy will be eventually held to the same standards of evidence as other types of treatament.

Nortomaso hit the nail right on the head. The relaxation condition was not considered an "active control." Rather, it was essentially a placebo used to control for the "non-specific" effects of attention and time. It has not been shown to be efficacious for panic, in and of itself.

Barlow's Panic Control Treatment (PCT) is the gold standard of psychotherapy for panic disorder. The focus of this treatment (which is essentially "CBT for panic disorder") is to provide interoceptive exposure with the aim of habituating to feared stimuli. The model is based on simple empirically-supported behavioral principles - and is often touted as our most successful psychotherapy for a specific condition. The treatment can be brief. I have successfully treated individuals over 3-4 months with weekly sessions.

The next step is to compare this psychodynamic treatment to PCT, to see if there is any incremental benefit to using it. Further, long-term follow-up studies will be necessary in order to determine whether there is differential time to relapse/recurrence.

Edited to add a link to excellent review of CBT for panic:

http://www.ncbi.nlm.nih.gov/entrez/..._uids=15842185&query_hl=6&itool=pubmed_DocSum

 

[maranatha]

It makes no sense psychologically, neurologically etc...

So what? I'm not claiming to be a fan of psychodynamic therapy(I don't have enough experience or knowledge to take an informed stance), but questioning the validity of a study b/c it doesn't fit into a theoretical construct in no ways disproves that the treatment is effective. This mistake has been repeated many times in the history of science. Quantum mechanics versus Newtonian physics is probably the best example. I realize that is an extreme example, but the goal of a study like this is not to find something that works within a preconceived theory. You may be perfectly correct in assuming that the placebo had more of a role to play then the therapy. That is another issue, though.