Among the sessions I attended at the Winter Meetings of the American Psychoanalytic Association, one stood out on the findings of a randomized control trial of a new and manualized psychoanalytic treatment for panic disorder, overseen by its principal researcher, Barbara Milrod of Cornell Medical Center in New York City. The presentation was chaired by Stuart Hauser, a leading analytic researcher, and discussed by Peter Fonagy.
I’m writing about it here because it is a hopeful and beautifully done addition to our armamentarium concerning the efficacy of psychoanalytic therapy. It adds to studies being done by Fonagy, Target and their group in London on Mentalization-Based Therapy, and by Otto Kernberg’s group at Cornell, White Plains on Transference Focused Psychotherapy. The studies apparently have a good deal of overlap in their systematic use of transference and basic analytic techniques applied to a brief therapy that is therefore much easier to test for outcome.
In this study, Dr. Milrod and her colleagues treated Panic Disorder – including such symptoms of acute anxiety as intense fear, chest pain, heart palpitations, and shortness of breath — precisely because Panic Disorder has been a focus of CBT and medication outcome studies. Since these studies have been based on 12 weeks of treatment, she designed her Panic Focused Psychotherapy (PFP) study to conform to these parameters so they can be compared. PFP treatment is manualized in a manner similar to Kernberg’s Transference Focused Psychotherapy (TFP), but this is much briefer — 12 weeks of twice-weekly weekly as opposed to a year of therapy for TFP.
(Patients were left on medication if they were already on it at the time they began the study, so that is not in the comparison. Obviously, if they were on medication at the beginning of the study, it was not in itself curing the panic disorder because symptoms of panic attacks had to be present for a subject to qualify for the study.)
Panic Focused Psychotherapy begins with initial evaluation of the symptoms, relating them to the surrounding circumstances and attendant feelings, exploration of the personal meaning of symptoms and episodes. Then the therapist works to identify relevant psychodynamic conflict, focusing commonly on issues of separation, autonomy, and anger. In the first phase, therapy aims for panic relief and reduced agoraphobia.
The second phase of PFP explores panic vulnerability by addressing transference manifestations, and working through the many situations of conflict. In this phase, therapy hopes to result in improved relationships, less conflict and anxiety in the experience of anger, separation and sexuality, and reduced recurrence of panic. Finally, a termination phase permits re-experience of conflict around separation and anger themes in the transference, because a frequent temporary recrudescence of symptoms during termination allows for a review of problems that can again lead to an enhanced ability to manage separation and experience autonomy.
In a paper published in February of 2007 in the American Journal of Psychiatry (164:2 pp 265-272) Dr. Milrod and her colleagues reported on the preliminary study that showed 73% efficacy compared to 39% for Relaxation Therapy. This study prepared the research for later comparison to medication and CBT. But at the presentation in January, Dr. Milrod presented preliminary data on the comparisons going forward with CBT. So far and unofficially, PFP holds up well against CBT and especially shows a better capacity to maintain gains months after the completion of treatment. Although the treatment is “manualized” it is not a rote treatment. The manual offers a guide as to what issues to focus on in evolving phases of therapy. There are compromises with the way we practice analytic therapy that are required to construct such a manualized treatment, but anyone who has read Michael Stadter’s excellent book “Object Relations Brief Therapy” (Jason Aronson, 1996) will recognize the enormous overlap in methodology. Stadter’s model is one of a combined focus on the symptom and the dynamic unconscious structure that underlies it, all treated in the transference using working through and a late focus on termination and loss. Brief analytic treatments can be tested, while it is exponentially more difficult to do so with open-ended, long term therapy. These studies, done in ways that can be compared directly to CBT and medication, offer to give us the ammunition to defend our trade in clear and legitimate ways that have, until recently, been sorely lacking. Peter Fonagy spoke with deep appreciation of Barbara Milrod’s study, particularly noting how arduous and time consuming such studies are, and how thoroughly and rigorously she and her colleagues were in the conduct of this study.
Webb MD’s Denise Mann reported on January 17 that, “The psychodynamic psychotherapy regimen used in the study was so successful that the American Psychiatric Association is in the process of changing its guidelines to reflect the new findings, according to researcher Barbara Milrod.”(Until now the APA has only endorsed CBT and medication as treatments for Panic Disorder.)
This research and the few comparable studies now going on are a cause for hope for our way of thinking and practicing. I look forward to more results from Dr. Milrod and her colleagues.