The New York Times today reported on a new study demonstrating that psychoanalytically-informed psychotherapy is effective for panic disorder. In fact, it had a very impressive response rate:
In Rigorous Test, Talk Therapy Works for Panic Disorder
By Benedict Carey
The field of psychoanalysis has struggled with a disabling internal conflict in recent years: whether to subject the therapy to rigorous testing, like the process through which new drugs are approved, or to insist that the insights it provides are self-evident and cannot be put under a microscope.
This internal debate has raged even as analysis, Freud’s open-ended talking cure, has become increasingly marginalized as a practice. But the ground rules may soon change.
Last week, a team of New York analysts published the first scientifically rigorous study of a short-term variation of the therapy for panic disorder, a very common form of anxiety. The study was small, but the therapy proved to be surprisingly effective in a group of severely disabled people.
The paper, which appeared in psychiatry’s flagship journal, The American Journal of Psychiatry, is one of the most significant steps in a small but growing effort to study how this so-called psychodynamic therapy works, and for whom.
The brand of therapy tested relies on core tenets of analysis, like the search for the underlying psychological meaning of symptoms. But unlike traditional psychoanalysis, it focused on relieving symptoms quickly, and was time-limited. Previous studies of similar approaches have shown some promise for other disorders, like depression.
“It is very exciting, because you rarely see this kind of therapy studied at all, and it was very rigorously done,” said Dr. Dianne Chambless, a professor of psychiatry at the University of Pennsylvania who was not involved in the study but is now collaborating with the researchers.
Dr. David H. Barlow, a psychiatrist at Boston University, said in an e-mail message that the study was too small to be conclusive but that “the authors should be congratulated for actually taking the first step in doing the hard work of beginning to evaluate treatments” that are widely used without good supportive evidence.
The researchers tested a pared-down version of analysis tailored specifically for panic attacks, the breathless, paralyzing dread that strikes some 1 percent to 2 percent of people, seemingly out of nowhere. Previous studies had found that other kinds of therapy — including exposure techniques, in which people learn to diffuse their anxieties by facing them one small step at a time — can relieve panic attacks in half to two-thirds of patients, depending on the severity and type of anxiety.
In the new experiment, Dr. Barbara L. Milrod, a psychiatrist at Weill Medical College of Cornell University, led a team of therapists who treated 49 men and women with a variety of anxieties. Some were agoraphobic, unable to ride the subway or visit certain parts of town. Others had symptoms of depression or of personality problems, like a disabling dependency on other people or an avoidance of social situations.
Half of the group received a form of relaxation training, in which they learned how to moderate their arousal by tensing and relaxing specific muscle groups. The other half received psychodynamic therapy, working with their therapist in two weekly sessions to understand the underlying meaning of their symptoms — when the reactions first started and how they might be linked to loss, broken relationships or childhood experiences that unconsciously haunted their current lives.
After 12 weeks, 39 percent of those working with relaxation techniques improved significantly on standard measures of anxiety and reported fewer panic-related problems in their relationships and work. But almost three-quarters of those receiving psychodynamic therapy reported similar benefits.
“This is best response rate I’ve seen in a controlled trial for panic,” Dr. Milrod said. “And the therapy was time-limited. I don’t think anyone would care if psychoanalysis cured panic in six years — snore. We wanted to know that what we were doing worked, that it wasn’t malpractice.”
Researchers from Columbia University, the Mount Sinai School of Medicine and Hunter College were also involved.
Studies of this brand of therapy are important for the thousands of therapists around the world who mix and match analytic techniques with other therapies. One former patient treated with this therapy began to have panic attacks after witnessing a young woman die of an illness, said her doctor, Fredric N. Busch, a Cornell psychiatrist and a co-author of the new study.
The patient, who was not a part of the study, described the death as deeply unfair, and in sessions explored perceptions of unfairness in her work and her life, including her childhood. “Once she was able to understand this pattern, the panic became less frightening, she felt safer and was eventually able to get rid of the symptoms,” Dr. Busch said.
The researchers said that even if this approach was not for everyone, it appeared to be especially beneficial for a particular group. In an analysis of individual patient’s responses, the researchers found that those who also had a personality disorder, like avoidant personality, showed significantly greater improvement than those whose symptoms were related solely to anxiety. Patients with multiple diagnoses are usually more difficult to treat.
“This finding was very surprising and there’s absolutely no precedent for it, as far as I know,” Dr. Milrod said.
See also the paper’s abstract:
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.
At last my psychodynamic colleagues are engaging in the difficult work of validating our treatments. These authors deserve much praise for the pioneering effort. Its nice, but not critical, that we also like the results!
February 6th, 2007