The Latest on Panic Attacks

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

Hot on the heels of a blog I posted on January 20 last, in which I referred to new research in the States that showed very positive outcomes for long term psychoanalytic therapy, comes another survey from the same neck of the woods.

This time, however, it is research that shows how modified and shortened psychoanalytic therapy of 12 weeks duration works for panic disorder.

It might seem like just another piece of research but in the field of psychoanalysis the existence of research is a quite a rarity. That’s why a recent report in the New York Times is interesting. A team of New York analysts published the first scientifically rigorous study of a short-term variation of analytic therapy for panic disorder, a very common form of anxiety. The study was small, the report said, but the therapy proved to be surprisingly effective in a group of severely disabled people.

The research paper appeared in American psychiatry’s premium journal, The American Journal of Psychiatry. The therapy it tested, unlike traditional psychoanalysis, focused on relieving symptoms quickly, and was time-limited. Previous studies had found that other therapies — including exposure techniques such as Cognitive Behavioural Therapy, 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.
So, again the principles of psychoanalysis have been tested and found to be robust. Granted the above study modified the therapy, thus satisfying the need for speed that is a hallmark of modern living, but the underlying principles held fast. It might not be enough to re-train behaviours and thoughts on the basis that new habits help us overcome old ones. What the outcome is saying is that there has to be fundamental change in the person’s understanding of what is going on, why it is happening, how that fits in with the entirety of their lives to date and how new possibilities can emerge in place of old, unhelpful solutions.
The only thing that should be added, and I fall on the side of traditionalists in this regard, is that the race to do things quicker is not always better. In most areas of human endeavour you will see an example of this: the food industry has given us fast food but has it improved our nutrition? Banking raced to speed up ways to give us large wads of cash. It led to an inevitable crash. Technology has speeded up our access to great vistas of knowledge and entertainment. But has it freed up our time to be more human and build better communities?
In this regard, the current study has an interesting quote from one of its authors. “This is best response rate I’ve seen in a controlled trial for panic,” Dr. Barbara 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.”
Note the word ‘snore’. That is not the language of classical psychoanalysis, not because it is against someone coming for 12 weeks or even 6 and then finishing. The fact is, they do. No, it is because 12 weeks does not suit everyone and to suggest it does is misleading. When people come for therapy, some want to be out as quick as possible but others don’t. And for those who don’t, that choice has to be there.
To assume there is nothing other than a panic disorder sitting in one’s consulting room is the ultimate disrespect. Panic disorder is a symptom, a sign that many other things are operating at an unconscious level for the client. Putting a short term focus on the symptoms runs the risk that deeper issues get ignored.
Yes, it is good to see positive results appearing in respected medical journals about psychoanalysis. But let’s not forget that psychoanalysis is different because it invests time - in the person who presents for therapy, in the human complexity that person represents and in the person behind the person telling us their story.

Surveying the Therapy Landscape

By Kevin Murphy, M.Sc.,
Psychoanalytic Psychotherapist
Dublin, Ireland.

One of the big questions for any therapy is, does it work? And in this regard, surveys backing up the success or otherwise of psychoanalytic psychotherapy have been very thin on the ground. In fact, most of the running has been done by the ‘newer’ therapies, those that offer short term, quick solutions, ones with ‘evidence-based’ data behind them. And, you have to include drug-based treatments that have been around since the 1950s that also take the limelight with the promise of a pill for every ill, not to mention reams of data to support their position.
By contrast, the longer term psychoanalytic approach, the one that invests time in each individual client, the one that goes behind the symptoms and looks for causes, the one that refuses to accept the simple answer or the short cut, the one that is based on a speaking relationship between client and therapist and that is the oldest, original form of psychotherapy; this is the one that has had very few surveys carried out. As a result it has seemed much like a sleeping giant for many years.
There is a change of attitude on this, however, and the current debate now within the psychoanalytic field internationally is why not research and survey? Why not let the world now that a) psychoanalsyis is not dead but very much alive in both practice and education and b) it has enormous benefits to offer. But the debate hinges on finding a way of researching and surveying that respects client confidentiality and does not impinge in any way on the all-important relationship between client and analyst.
In this context it was interesting, therefore, to see new research in the prestigious Journal of the American Medical Association (JAMA) that supports the effectiveness of the psychoanalytic approach in glowing terms. The research was published in the October edition and, interestingly, this is the first such review to appear in a major medical journal.
In a comment on the findings, the New York Times said the studies on which it was based are probably not widely known among US doctors. And presumably that also applies to Europe and beyond.
Essentially, it gathered together 23 separate studies that used the psychodynamic approach (psychodynamic is another word used for psychoanalytic) covering over 1,000 patients who were in analysis for anything from over a year up to many years. It put these studies through a rigorous further analysis or 'meta-analysis' and came up with the following findings.
Intensive psychoanalytic therapy, or the ‘talking cure’ as it was named by Freud, when it is given three times a week relieved symptoms more than did short term therapies. Commenting on this, the same newspaper quoted Bruce Wampold, chairman of the department of counselling psychology at Wisconsin University as saying that although the study prompts the need for further study, it now contradicts the notion that cognitive or other short-term therapies are better than any others.
The studies that the investigators examined tracked patients with a variety of problems, among them severe depression, anorexia nervoxa and personality disorders. Psychoanalytic therapy showed significant, large and stable treatment effects which actually increased from the end of therapy until follow-up assessments were made some time later. In effect, the study is saying that the positive changes that can result are so stable and effective that they continue working even after the therapy has finished. That’s probably not going to come as a surprise to psychoanalytic psychotherapists but it is quite a claim to make publicly and one that hasn’t been highlighted in the past.
The New York Times report quoted Dr Andrew Gerber, a psychiatrist at Columbia University as saying that the research suggests that if you want to make lasting improvements you’ve got to use longer-term therapy.
The study compared the psychoanalytic treatment of personality, eating, and other disorders with therapeutic treatments that included cognitive-behavioural therapy, cognitive-analytic therapy, dialectical-behavioural therapy, family therapy, supportive therapy, short-term psychodynamic therapy, and psychiatric treatment.
The results indicated that after treatment with long term psychoanalytic psychotherapy patients on average were better off than 96% of the patients in the comparison groups.
In 5 studies of analytic therapy alone, the majority of patients had complex depressive and anxiety disorders and the majority of patients were also classified with chronic mental disorders. According to the results, long term analysis on its own yielded significantly large effects in overall outcome, general psychiatric symptoms, and social functioning in follow-up testing in all outcome areas.
Its a long study and quite complex from a statistical analysis point of view but in their conclusion, the authors suggest that further studies of psychoanlytic treatment are now required in order to unearth more hidden facts about this sleeping giant of the therapy world.
They also suggest further surveys be carried out that might compare costs of long term versus short term therapy because in spite its long term nature, analysis and the psychodynamic/psychoanalytic approach was found to be cost-effective in some of the studies they looked at. Even though it took longer and cost more, the positive effects lasted longer and kept on going after the therapy ended. Which is another thing you rarely hear being mentioned.