Talk therapy works for panic disorder

Psychoanalytic therapies have been in professional use for over a century, but a new study from physician-scientists at NewYork-Presbyterian Hospital/Weill Cornell Medical Center is the first to show that a classic psychoanalytic talk therapy is efficacious in treating panic disorder.

Panic disorder remains a common, debilitating condition, accounting for more than 20 percent of U.S. hospital emergency room visits. Patients with the condition are plagued by sudden, uncontrolled symptoms such as panic, dizziness, and heart palpitations, as well as chest and abdominal pain.

The small but significant study, involving 49 patients, compared 12 weeks of twice-weekly psychodynamic psychotherapy sessions to another well-known approach, applied relaxation training (ART).

"The psychoanalytic strategy was highly effective, achieving nearly double the level of patient response by the end of treatment as compared to ART," says Dr. Barbara Milrod, the study's lead author and associate attending physician at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. She is also associate professor of psychiatry at Weill Cornell Medical College.

The findings are significant because the trial, while preliminary, is among the first to prove clinical efficacy for a psychoanalytic therapy for any major psychiatric disorder, Dr. Milrod says.

Her team published their findings in the American Journal of Psychiatry.

"Right now, two therapies -- cognitive behavioral psychotherapy (CBT) and the use of antidepressant or anti-anxiety drugs such as selective serotonin reuptake inhibitors (SSRIs) -- are the main forms of treatment for panic disorder in the United States," Dr. Milrod explains.

However, studies suggest that up to half of patients may not respond to either of these approaches. What is more, many patients, such as women during pregnancy, prefer not to take a pharmaceutical therapy, lending urgency to the notion that patients need effective, non-pharmaceutical options in treating panic disorder.

That is why there has been a renewed interest in psychodynamic psychotherapy. "This form of talk therapy has actually been around since the beginning of the 20th century, and it's still practiced by many psychiatrists and psychologists across the U.S. today," Dr. Milrod says.

Unlike CBT -- which relies on exposure to panic triggers, and a highly structured set of exercises aimed at easing attacks -- psychodynamic psychotherapy has a different focus.

"It's really aimed at getting patients to understand the underlying emotional meaning of their panic, its root psychological causes," Dr. Milrod says. "Once that is achieved, patients can acknowledge previously unacceptable feelings and ideas, which have led to panic, as they arise."

For example, in one case highlighted in the study, a respected professional musician was beset by panic attacks so severe they kept her from performing. During her psychodynamic psychotherapy sessions, she and her doctor traced the source of her panic to her relationship with her highly critical and demanding mother.

"Her panic attacks remitted through exploration of these issues," the study authors write, and the musician "managed to give a widely attended performance on her instrument that won great critical acclaim."

Still, as anecdotal successes like these cannot prove the general effectiveness of psychodynamic psychotherapy, Dr. Milrod's team compared the treatment to ART in a 12-week randomized, controlled clinical trial.

"We did not compare psychodynamic psychotherapy to CBT, but used ART -- a standard therapy that has often been used in trials aimed at assessing the effectiveness of other treatment approaches," she says. ART is a structured, relaxation-focused approach with similarities to CBT.

The results -- tabulated by Weill Cornell Professor of Biostatistics in Psychiatry Dr. Andrew Leon -- were impressive.

The 26 patients in the Panic-Focused Psychodynamic Psychotherapy (PFPP) group had a greater reduction in their symptoms compared to the 23 patients in the ART group, the researchers report. In fact, by the trial's end, 73 percent of patients treated with the psychoanalytic approach met criteria for "response," using standard definitions of "response" criteria in the field, compared to just 39 percent of those in the ART cohort.

"It's important to note that this trial is small, so no definite conclusions can be drawn at this point as to efficacy. Efficacy is considered well-established once results such as these are replicated. However, based on these results, we have already begun a much larger, two-site clinical trial in collaboration with researchers at the University of Pennsylvania," Dr. Milrod says. "That trial will compare the effectiveness of psychodynamic psychotherapy to that of both ART and CBT."

Right now, the important take-home message for patients battling panic disorder is that psychoanalytic treatment may provide a much-needed therapeutic option. We know that when it comes to panic disorder -- and psychological disorders in general -- not everyone is going to respond to one therapy," Dr. Milrod said. "It's really important to conduct rigorous trials like these, to let patients know that they have a real choice."

This study was funded by grants from the National Institute of Mental Health and a fund in the New York Community Trust established by DeWitt Wallace.

Co-researchers included Dr. Fredric Busch, Dr. Marie Rudden, Dr. John Clarkin, Dr. Wendy Turchin, Dr. Ellen Toby Klass, Elizabeth Graf and Jed J. Teres -- all of NewYork-Presbyterian/Weill Cornell and Weill Cornell Medical College; senior author Dr. M. Katherine Shear and Dr. Meriamne Singer of NewYork-Presbyterian Hospital/Columbia University Medical Center and the Columbia University College of Physicians and Surgeons; Dr. Andrew Aronson of Mount Sinai School of Medicine; and Dr. Michael Schwalberg of Hudson Valley Psychology Associates in Kingston, N.Y.

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