The American Psychiatric Association Practice Guideline for the Treatment of Patients With Panic Disorder: Recommendations and Controversies

Fredric N. Busch, MD and Barbara L. Milrod, MD

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Psychodynamic Psychotherapy

According to the guideline, psychodynamic psychotherapy may produce optimal long-term outcome for some patients when combined with short-term treatment, such as CBT or medication (p 10). The therapy focuses on elucidating mental processes outside the patient's awareness that can lead to symptoms and promotes an emotional and cognitive understanding and an integration of the elements of psychic conflict, including impulses, conscience, and defensive patterns. There are many case reports of effective treatments but no randomized placebo-controlled trials. Research that supports the psychodynamic approach includes studies demonstrating that panic patients perceive their parents to be overprotective and less caring[7] and studies indicating the presence of significant recent and early life events preceding panic onset.[8,9,10,11] One study demonstrated the usefulness of psychodynamic psychotherapy as an adjunct for medication, significantly improving long-term outcome of medication treatments.[12] An open clinical trial of one form of manualized psychodynamic psychotherapy for panic disorder, PFPP, is now under way.[13]

Although psychodynamic psychotherapy is recommended less strongly than CBT or medication, the guideline suggests that psychodynamically informed management and/or psychodynamic treatment may be helpful in treating patients with comorbidity: "Specific psychosocial therapies (including psychodynamic psychotherapy) may be useful to address comorbid disorders or environmental or psychosocial stressors in patients with panic disorder and are frequently used in conjunction with CBT and/or antipanic medications" (p 3). In addition, it is recommended in cases in which other treatments are ineffective: "Patients who do not respond as expected to medication or CBT, or who have repeated relapses, should be evaluated for possible addition of a psychodynamic or other psychosocial intervention" (p 22).

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