Psychoanalytic Psychotherapy for Panic Disorder

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Milrod B, Leon A, Busch F, Rudden M, Schwalberg M, et al. 2007. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. AJP 164: 265-72.

Clinical Question: 43 yo female in PEC with panic disorder with agoraphobia- symptomatic unresolved despite SSRI and CBT. Are there additional effective treatments available?

Question Type: Therapy

Description of intervention:

Panic Focused psychodynamic psychotherapy: manualized and time-limited; goal: to uncover unconscious conflicts behind panic symptoms: i.e. separation and autonomy, anger; to work through the conflicts via transference; and to re-experience conflicts w/ therapist and to articulate underlying feelings in an effort to reduce symptoms of panic; no homework and no emphasis on exposure therapy

Validity Criteria: this study fulfills validity criteria and was adequately powered, although small, N=49

• Follow-up: follow-up complete; except for dropouts, all patients properly accounted for at conclusion- 2/26 psychotherapy dropouts, 8/23 relaxation dropouts- treated as intention-to-treat, last observation forward
• Randomization: randomized and concealed from evaluators
• Intention to treat: pts analyzed in the groups to which they were randomized, all randomized patient data was analyzed
• Similar groups: treatment and control groups were not similar: more and cluster B in relaxation group
  • Male: 15% in Psychotherapy vs 47% in Relaxation
  • Cluster B: 11% in Psychotherapy vs 21% in Relaxation
• Blinding: patients and those giving treatment were not blinded; however evaluations were performed by blinded clinicians
• Equal treatment: aside from the intervention, groups were treated equally

Study Design Type: Randomized Controlled Trial

• Duration: 12 week study, 2 sessions per week, evaluated at baseline, termination and post-tx: f/u at 2,4,6,12 months
• Setting: NY metropolitan area; academic, outpatient setting
• Patients/Pop: n = 49, DSM-IV Panic disorder diagnosis, included axis II and pt’s on psychotropic meds
• Intervention/exposure: Panic-focused Psychodynamic Psychotherapy vs Applied Relaxation Training
• Outcomes:
  • Primary Outcome: Panic Disorder Severity Scale (PDSS)
  • Secondary Outcomes: Sheehan Disability Scale, HAM-D, HAM-A

Main Results:

Greater reduction of symptoms severity in Panic-focused psychodynamic psychotherapy than in relaxation training. Change from baseline to termination: large effect size in reduction in symptoms between psychotherapy vs relaxation training

• PDSS: Between group effect size: 0.95 (very large), stat sig, Psychotherapy ↓ 8.1 pts, Relaxation ↓ 3.2 pts
• Sheehan Disability Score (psychosocial functioning): between group effect size 0.73 (mod large), stat sig
• HAM-D, HAM-A: no stat sig change

Conclusions:

Panic-focused CBT and pharmacotherapy (SSRIs, TCAs, Benzos, and MOAIs) are first line treatments for panic disorder, but many patients do not respond (29-48%). This study is the first to evaluate a manualized psychodynamic psychotherapy for panic disorder and shows preliminary results of superior efficacy in reducing panic symptoms (PDSS) and improving quality of life (Sheehan) when compared to Applied Relaxation Training. Although the study was adequately powered, it was small. Additionally, groups were not similar in all respects: relaxation group had more men and cluster B, which reveals that randomization in small studies does not guarantee equal distribution. The higher dropout rate in the relaxation group of 34% compared to psychotherapy of 7% also proved to be a weakness; this could bias the data in favor of the psychotherapy group, as dropouts were considered non-responders. However, the lesser dropout rate of psychotherapy may be evidence for greater tolerability, which is important to consider in light of patient compliance. Another weakness was infrequent evaluation during treatment, which the authors justified by concern that more frequent testing would interfere with transference intensity during psychotherapy. Despite its weaknesses, the study did show a statistically significant large effect size reduction of symptoms of panic on PDSS for manualized, panic-focused psychodynamic psychotherapy. In practice, this may be a therapeutic option for patients who fail the current standard of treatment: CBT and medication. Since pt’s on pharmacologic treatment were permitted to continue it, no medication comparisons can be inferred from this study design. Similarly, no comparisons can be made to CBT. Thus, further research should evaluate Panic-Focused psychodynamic psychotherapy vs CBT and/or medication.

Synopsis:

In this RCT lasting 12 weeks, 49 patients with panic disorder, manualized panic-focused psychodynamic psychotherapy showed superior efficacy to applied relaxation training after 24 sessions as rated by blinded independent evaluators. This is the first study to evaluate an operationalized, testable form of psychotherapy for panic-disorder, which is distinguished from CBT by its lack of homework or emphasis on exposure, and its focus on underlying meaning/conflicts of the patient’s panic symptoms. As this study did not compare psychotherapy to current standards of treatment for panic disorder, further research to compare panic-focused psychodynamic psychotherapy to panic-focused CBT/and or medication would be worth studying.

Presented by Leigh Fylstra, MD, on 2/19/07