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AIM: This study aimed to investigate whether separation anxiety (SA) constitutes a dimension related to age at onset of panic disorder (PD), in homogeneous subgroups of outpatients with PD, based on their age of onset and symptom severity.METHODS: A sample of 232 outpatients with PD was assessed with the Panic Disorder Severity Scale (PDSS) and the Sheehan Disability Scale (SDS) for functional impairments. Separation anxiety was evaluated using structured interviews and questionnaires. We applied a K-Means Cluster Analysis based on the standardized "PD age of onset" and "the PDSS total score" to identify distinct but homogeneous groups.RESULTS: We identified three groups of patients: group 1 ("PD early onset/severe", N = 97, 42%, onset 23.2 ± 6.7 years), group 2 ("PD early onset/not severe", N = 76, 33%, onset 23.4 ± 6.0 years) and group 3 ("PD adult onset/not severe", N = 59, 25%, onset 42.8 ± 7.0 years). Patients with early onset/severe PD had significantly higher scores on all SA measures than PD late-onset/not severe. Regression analyses showed that SA scores, but not PDSS scores, were predictive of impairment in SDS work/school, social life, and family functioning domains.CONCLUSIONS: Our data indicate a significant relationship between SA and PD with an earlier age of onset and an impact on individual functioning. This may have important implications for implementing preventive interventions targeting early risk factors for the subsequent onset of PD.

Neuroimaging studies point to neurostructural abnormalities in youth with anxiety disorders. Yet, findings are based on small-scale studies, often with small effect sizes, and have limited generalizability and clinical relevance. These issues have prompted a paradigm shift in the field towards highly powered (i.e., big data) individual-level inferences, which are data-driven, transdiagnostic, and neurobiologically informed. Here, we built and validated neurostructural machine learning (ML) models for individual-level inferences based on the largest-ever multi-site neuroimaging sample of youth with anxiety disorders (age: 10-25 years, N=3,343 individuals from 32 global sites), as compiled by three ENIGMA Anxiety Working Groups: Panic Disorder (PD), Generalized Anxiety Disorder (GAD), and Social Anxiety Disorder (SAD). ML classifiers were trained on MRI-derived regional measures of cortical thickness, surface area, and subcortical volumes to classify patients and healthy controls (HC) for each anxiety disorder separately and across disorders (transdiagnostic classification). Modest, yet robust, classification performance was achieved for PD vs. HC (AUC=0.62), but other disorder-specific and transdiagnostic classifications were not significantly different from chance. However, above chance-level transdiagnostic classifications were obtained in exploratory subgroup analyses of male patients vs. male HC, unmedicated patients vs. HC, and patients with low anxiety severity vs. HC (AUC 0.59-0.63). The above chance-level classifications were based on plausible and specific neuroanatomical features in fronto-striato-limbic and temporo-parietal regions. This study provides a realistic estimate of classification performance in a large, ecologically valid, multi-site sample of youth with anxiety disorders, and may as such serve as a benchmark.

The authors review the past and current challenges in psychotherapy training, research, and practice and the state of psychotherapy in the context of current training and funding, the COVID-19 pandemic, and the current era's pursuit of novelty. Where does the field stand, and where should it go?

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians’ beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians’ intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = −0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = −.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

The 2020 COVID-19 pandemic has abruptly overwhelmed normal life. Beyond the fear and fatality of the virus itself comes a likely wave of psychiatric disorders. Simultaneously, social distancing has changed overnight how psychiatrists and other mental health professionals must treat patients. Telepsychotherapy, until now a promising but niche treatment, has suddenly become treatment as usual. This article briefly reviews the limited clinical evidence supporting different modes of telepsychotherapy, then focuses on how remote therapy affects clinicians and their patients.

To examine process of changes in two distinct psychotherapies-cognitive-behavioral therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP). Two hypothesized processes of change-misinterpretation of bodily sensations and Panic Specific Reflective Function (PSRF)-were tested in the CBT and PFPP arms of the Cornell-Penn Study of Psychotherapies for Panic Disorder. The Brief Bodily Sensations Interpretation Questionnaire (BBSIQ) measures misinterpretation of bodily sensations-a focus of CBT interventions. PSRF, a target of PFPP, assesses the capacity to reflect on the underlying meaning of panic symptoms. A sample of 138 patients (37.7% men, 72.56% Whites, and 16.7% Latinx) with primary Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) panic disorder were included in the present analyses. Mixed effects models tested the effects of early change in BBSIQ and PSRF (intake through Week 5) on subsequent change in the Panic Disorder Severity Scale (PDSS; Week 5 through termination). Early change on both PSRF and BBSIQ predicted subsequent change in panic severity across the two treatments. As predicted, PSRF changed more in PFPP than in CBT, but, contrary to expectation, BBSIQ showed comparable changes in both groups. Counterintuitively, CBT patients benefited more in terms of panic symptom improvement when their PSRF improved than did PFPP patients. This is the first demonstration of general processes of change (PSRF and BBSIQ) across psychotherapies for panic disorder, suggesting that to the extent patients change their beliefs about the meaning of panic, their panic symptoms improve in time-limited, panic-focused psychotherapies. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Background It is not known whether common anxiety/mood comorbidities of panic disorder (PD) improve with panic-focused psychological treatment, nor whether there is differential efficacy between therapies in treating comorbidities. Methods In a randomized controlled trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), symptomatic comorbidities of agoraphobia, MDD, GAD, and social anxiety disorder (SAD) were assessed pre-to-post treatment with the Anxiety Disorders Interview Schedule (ADIS). Comparative efficacy of CBT versus PFPP for treating comorbid disorders was tested at termination and 1 year's follow-up. Covariance between panic and comorbidity improvements was also analyzed. Results Most treatment completers (n = 120) evidenced diagnostic remission of their comorbidity (range = 54–69%), which typically reflected a subclinical score on the ADIS (mean range = 1.3 to 1.8). These improvements were generally retained at follow-up. However, patients with MDD dropped out significantly more often (HR = 2.79). No significant symptom change or remission differences emerged between CBT and PFPP for any comorbidity at termination or at follow-up. Panic change was strongly related to improvements in agoraphobia (r = 0.70) and MDD (r = 0.53), moderately related for GAD (r = 0.31), and not significantly related for SAD (r = 0.20). Discussion Patients completing panic-focused psychotherapies often experience meaningful remission for diagnoses of agoraphobia, MDD, GAD, and SAD, with no detectable differences between treatments, although sample sizes for the MDD and SAD comparisons were small. In addition, additional efforts may be needed to keep MDD-comorbid patients in treatment.

Safety behaviors (SBs) are generally perceived as ‘dysfunctional’ emotion-regulation strategies that reduce physical symptoms and prevent unrealistic feared consequences of panic attacks. However, it is unclear whether all types of SBs are a hindrance or whether some may promote self-regulation in treatment. We propose that the type of SBs might explain some of the variability between panic disorder (PD) patients, and might help to predict why treatment is more successful for some than for others. In this secondary analysis of a subsample of 65 PD patients who received Cognitive Behavioral Therapy in a two-site randomized controlled trial, we examined the associations between type of SB and pre-treatment characteristics and their predictive value on trajectories of change in treatment process and outcome (panic symptoms, interpersonal problems, alliance). An observer-rating system for five types of SBs (avoidance/distraction/control-function and object/people-focus) was developed and applied to videotaped early treatment sessions, with high reliability. Patients with higher levels of people-focused SBs reported higher levels of panic symptoms pre-treatment at both treatment sites. These people-focused SBs predicted poorer treatment response on panic symptoms at one of two sites. Avoidance, control, or distraction-function and object-focused SBs were not associated with treatment process or outcomes. People-focused SBs may worsen PD symptoms, and possibly slow treatment progress, although this latter finding was not consistent across sites. This study differentiated between types of SBs and identified people-focused SBs as possible predictor of symptom change in CBT for PD—potentially relevant for efforts to improve treatment response.

BackgroundThe hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)].MethodsThirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes.ResultsBaseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome.ConclusionsThis is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the ‘limbic’ AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.

This chapter provides an overview of the central psychodynamic techniques of the middle phase of TFPP. Core intrapsychic conflicts that contribute to PTSD symptoms are identified and actively addressed. Interpretation of defenses aids in the elucidation of conflicts. A prominent defense in PTSD, identification with the aggressor, is described in more depth. Exploration of the transference is discussed with attention to the ways in which core conflicts emerge with the therapist. Patients with PTSD trigger particularly intense countertransference reactions, knowledge of which furthers the therapeutic process. The technique of working through is articulated, in which the therapist and patient elucidate how various conflicts and defenses emerge across a range of symptoms, contexts, and relationships. Case vignettes are used to illustrate these approaches.

After briefly reviewing the psychoanalytic view of mental life, including the influence of the unconscious on mental life and symptoms, this chapter describes the impact of trauma from the psychodynamic viewpoint. Disruptions in narrative coherence, repetition and re-experiencing, intrapsychic conflicts, dissociation, defenses, intense negative affects, and disruptions in trust that result from trauma are described. Clinical examples are presented to illuminate these factors. In addition, the relevance of the patient’s pretrauma history, their attachment style and mentalization skills, and the specific nature of traumatic experience on the impact of trauma and associated symptoms is elaborated.

This chapter highlights the importance of the termination phase to the practice of TFPP. Attachment dysregulation and feelings of abandonment and rage come to the fore within the therapeutic relationship during termination. Careful handling of this process is crucial in helping the PTSD patient move past symptoms to effect therapeutic change. Issues that commonly arise during termination are feelings of loss and mourning, anxiety surrounding separations, aggravation of mistrust and anger, and fantasies and fears of helplessness. Feelings of pride and gratitude may also emerge. Termination is a challenging time in TFPP, and this chapter also focuses on common countertransference concerns and ways of avoiding pitfalls. Clinical vignettes of TFPP terminations are provided.

This book, which operationalizes and articulates in detail a unique, brief, tested psychodynamic psychotherapy for Post-Traumatic Stress Disorder, Trauma Focused Psychodynamic Psychotherapy [TFPP], describes how to perform this helpful treatment. The book provides tailored psychodynamic background that underpins these approaches, and explains the different phases of treatment. Additionally, it articulates common underlying dynamics of PTSD that the treatment commonly addresses in patients to bring about symptomatic relief. TFPP is being tested in two diverse populations: military Veterans with PTSD who are receiving care at three Veterans Administration Hospitals, and also among LGBTQ patients with PTSD. The book is focused on the authors’ experiences treating Veterans and many clinical examples are provided demonstrating how to work with these principles and approaches. In general, patients and therapists have found the treatment to be an extremely useful tool. Veterans have gained insight into the impact of traumatic experiences on various aspects of their lives and had improvements in dissociation, interpersonal engagement, anxiety, and anger/hostility. TFPP appears to be particularly effective for patients with prominent avoidance symptoms and those who are unwilling or unable to recount the details of their trauma directly. Patients have been found to be more affectively engaged and better connected to others (including the therapist) following treatment.

This chapter provides an extended case example of a 21 session treatment of a patient with TFPP. Pablo, a 27-year-old mixed Latino male Army Veteran who served in Afghanistan, presented with generalized anxiety, severe separation anxiety, and PTSD. In addition to his severe anxiety, panic attacks, hypervigilance, nightmares, and intrusive memories, Pablo complained of being in a “fog.” Symptoms began when a Humvee exploded next to Pablo. The therapist noted the patient’s description of feeling “trapped in a foxhole” with his painful memories of abuse and neglect in childhood and anger in current relationships. The therapist helped Pablo understand that he directed this anger toward himself, seeing himself as bad or inadequate, accepting his attackers’ view of him. The therapist linked the emotional impact of the Humvee explosion to a familiar set of anxieties and concerns following certain childhood experiences, and helped Pablo see how the pain of his early relationships and losses shaped his current fears and relationship choices. In the course of TFPP, Pablo became more comfortable expressing his anger and fears about his childhood, his military trauma and his current relationships. Symptoms and defenses and their origins and meanings were understood in the context of the relationship Pablo’s with his therapist (the transference). At termination Pablo was significantly improved; he no longer met DSM criteria for PTSD or other anxiety disorders. He felt much less affected by the “fog” and more capable of addressing problems in his life and moving forward with his goals and desires.

One of the key differences between TFPP and more open-ended psychodynamic psychotherapy is its specific focus on symptoms of PTSD throughout the treatment. This chapter outlines ways in which the therapist can focus psychodynamic psychotherapy on specific PTSD symptoms. These include difficulties with trust and paranoia, symptoms of re-experiencing the trauma(s), dissociation and avoidance, and guilt and a sense of “badness.” Approaches for fostering insight into these symptoms through a psychodynamic lens are all accompanied by illustrative clinical examples. Development of a psychodynamic formulation for the patient with PTSD is then articulated by linking symptoms, their precipitants, their meanings in the context of early and more recent relationships understood through the lens of the transference, and their defensive functions. The clinical vignettes show how the evolution of a more cohesive and positive self-narrative permits further self-exploration and access to memories, and the possibility of more flexibility in the patients’ life choices.

This chapter provides descriptions and clinical examples to illustrate core psychodynamic techniques as they are adapted to the work of trauma-focused psychodynamic psychotherapy (TFPP): clarification, confrontation, interpretations, and utilization of patient dreams. Clarification aids the patient in gaining distance and objectivity. Confrontation is designed to help patients recognize contradictory thoughts and feelings. Interpretations tie observed behaviors or thought patterns to the emotional dynamic factors that may give rise to them. Because a core symptom of post-traumatic stress disorder (PTSD) involves re-experiencing traumas through dreams, a focus on the approach to dreams is particularly relevant in this population, and TFPP is the only operationalized psychotherapy for PTSD that makes active use of dreams to gain an understanding of emotional causes of distress. The chapter also illustrates the use of the transference and its interpretation and describes common countertransference constellations that arise. Due to the nature of the impact of trauma, transference and countertransference reactions can be particularly intense and ways that the therapist can effectively use these reactions to guide the treatment are discussed.

This brief chapter incorporates some of our team’s observations about practicing TFPP during the COVID-19 pandemic. For many of our patients, access to care became more fractured, whereas for other patients, session attendance became easier and even resulted in better access to their inner lives. The impact of the necessity to switch to telehealth is discussed, as well as the effects of isolation on the one hand and tensions surrounding quarantine situations on the other. The chapter discusses one case of a Vietnam war Veteran for whom the experience of the lockdown exacerbated anger and mistrust he had experienced during the war. In a second case the patient experienced being infected with COVID as yet another experience of abuse, and struggled with his angry response. Patients’ responses are necessarily filtered through their developmental histories, traumatic experiences, and individual dynamics. TFPP helps to delineate how patients’ symptoms and relationships are affected, creating opportunities for further therapeutic work.

This chapter examines the initial approach to PTSD symptoms using TFPP. Symptoms serve as a lens through which to explore and address contributory emotions, conflicts, and defenses. Symptoms may express or function to ward off intolerably painful emotions generated by the trauma. The therapist works to link the symptoms to relevant traumatic events, which patients have often avoided via dissociation or other defenses. The therapist is empathic with patients’ distress in describing trauma and also works with patients’ reactions to better understand the impact of trauma. Exploration of the context, emotions, and meanings of symptoms helps patients to gain a clearer understanding of past and present precipitants and the reasons that symptoms continue. The therapist additionally explores how developmental experiences, including early traumatic events, affect patients’ reactions to subsequent trauma.

This chapter outlines core symptoms and mental states common to many patients with PTSD. The symptoms and their meaning, which necessarily will have individual variations, are presented and described through a psychodynamic lens. Fundamental elements of TFPP are described, Common approaches and pitfalls are presented all with clinical descriptions. Central difficulties that patients with PTSD commonly have in engaging in psychotherapy are outlined, including disruptions in narrative coherence, core problems of trust, and feelings of shame, guilt and alienation, that necessarily affect the way therapy can proceed. Approaches to these problems are highlighted, including ways to help build a safe therapeutic environment.

Behavioral Inhibition (BI) is an early temperamental trait characterized by shyness, withdrawal, avoidance, uneasiness, and fear of unfamiliar situations, people, objects, and events. The DSM-5 refers to behavioral inhibition as a temperamental factor related to neurodevelopmental conditions in childhood, including attention deficit hyperactivity disorder, selective mutism, and specific phobias; and to its influence on adult anxiety disorders including social anxiety disorder, agoraphobia, and generalized anxiety disorder, but, interestingly, not separation anxiety disorder (SAD). However, there are phenomenological overlaps between BI and SAD. We aimed to explore whether there is a correlation between BI as an early temperamental trait and childhood or adult separation anxiety disorder.The study was conducted in 377 consecutive adults (mean age 40.2±12.4 years) outpatients with anxiety and mood disorders as the principal diagnosis, grouped on the presence/absence of a DSM-5 diagnosis of childhood or adult separation anxiety disorder. Separation anxiety was assessed by the Structured Clinical Interview for Separation Anxiety (SCI-SAS) and the Adult Separation Anxiety Checklist (ASA27). Behavioral inhibition was assessed by the Retrospective Self-Report of Inhibition (RSRI).The four comparison groups included: 1) 168 patients without childhood or adult SAD, 2) 81 with adult SAD, 3) 97 with both adult SAD and childhood SAD, and 4) 31 with childhood SAD only. The group with both adult and childhood SAD had the highest scores on RSRI total and sub-scale scores. Both groups with adult SAD had significantly higher RSRI scores than the group with only childhood SAD or without SAD. Significant bivariate correlations were found between ASA-27 scores and RSRI scores. Correlations between RSRI scores and measures of anxiety and depressive symptoms were significantly weaker than those on the ASA-27. Regression analyses showed a significant predictive value of RSRI scores on ASA-27 total score, but not of age of onset of SAD.BI has an onset in the very first years of life and may represent a potential developmental endophenotype for later anxiety disorders. Our findings indicate that BI and separation anxiety are connected in individuals with affective and anxiety disorders. This may have important clinical and therapeutic implications for preventive interventions.

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.

Introduction Separation anxiety disorder (SAD) comprises one aspect of attachment dysregulation or insecurity. Although SAD aggravates posttraumatic stress disorder (PTSD) risk, no clinical research has tracked how many patients with PTSD have SAD, its clinical associations, or its response to PTSD treatment. Our open trial of interpersonal psychotherapy (IPT) for veterans with PTSD assessed these SAD domains. Methods Twenty-nine veterans diagnosed with chronic PTSD on the Clinician-Administered PTSD Scale were assessed for SAD using the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and for Symptom-Specific Reflective Function (SSRF), another dysregulated-attachment marker capturing patients' emotional understanding of their symptoms. Patients received 14 IPT sessions for PTSD with assessments at baseline, Week 4 (SCI-SAS and SSRF), and termination for SAD, PTSD, and depression. Results At baseline, 69% of patients met SAD criteria. Separation anxiety did not correlate with baseline PTSD severity, depressive severity, or age when traumatized; patients with and without SAD had comparable PTSD and depression severity. Patients with baseline comorbid SAD who completed IPT (N = 17) reported significantly improved adult separation anxiety (p = .009). Adult SAD improvements predicted depressive improvement (p = .049). Patients with SAD showed a stronger relationship between early SSRF gains and subsequent adult SAD improvement (p = .021) compared with patients without SAD. Discussion This first exploration of dysregulated/insecure attachment features among patients with PTSD found high SAD comorbidity and adult SAD improvement among patients with SAD following IPT. Highly impaired attachment patients normalized attachment posttreatment: 14-session IPT improved attachment dysregulation. This small study requires replication but begins to broaden clinical understanding of separation anxiety, attachment dysregulation, and PTSD.

The authors describe a psychodynamic psychotherapeutic approach to posttraumatic stress disorder (PTSD), trauma-focused psychodynamic psychotherapy. This psychotherapy addresses disruptions in narrative coherence and affective dysregulation by exploring the psychological meanings of symptoms and their relation to traumatic events. The therapist works to identify intrapsychic conflicts, intense negative affects, and defense mechanisms related to the PTSD syndrome using a psychodynamic formulation that provides a framework for intervention. The transference provides a forum for patients to address feelings of mistrust, difficulties with authority, fears of abuse, angry and guilty feelings, and fantasies.

Objective: This study examines whether, in panic-focused psychodynamic psychotherapy (PFPP), interpretations of conflicts that underlie anxiety (panic-focused or PF-interpretations) are specifically associated with subsequent panic disorder (PD) symptom improvement, over and above the provision of non-symptom-focused interpretations. Method: Technique use in Sessions 2 and 10 of a 24-session PFPP protocol was assessed for the 65 patients with complete outcome data randomized to PFPP in a two-site trial of psychotherapies for PD. Sessions were rated in 15-min segments for therapists’ use of PF-interpretations, non-PF-interpretations, and PF-clarifications. Robust regressions were conducted to examine the relationship between these interventions and symptom change subsequent to the sampled session. Interpersonal problems were examined as a moderator of the relationship of PF-interpretations to symptom change. Results: At Session 10, but not at Session 2, patients who received a higher degree of PF-i...

BACKGROUND: No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD. METHODS: In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity. RESULTS: 37% and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). While there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (p = 0.007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost). CONCLUSIONS: PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

Mentalization-how people understand their own minds and those of others-is an attachment-based, normative, cognitive, and affective capacity important to interpersonal relations and to certain kinds of psychotherapy. Mentalization seems related to aspects of, and may hold important implications for, interpersonal psychotherapy (IPT). Weissman and colleagues' IPT manual does not explicitly describe improvement in mentalization as a targeted outcome of therapy, but IPT may utilize mentalization as an underlying process. Recent theory emphasizes the applicability of a mentalization model to many, if not all, types of psychotherapy and suggests particular value for affect-focused and socially focused psychotherapies such as IPT, despite IPT's differences in focus and diagnostic targets from mentalization-based treatments. This article reviews the overlap of these approaches and suggests the potential of mentalization to mediate IPT outcomes. ispartof: AMERICAN JOURNAL OF PSYCHOTHERAPY vol:72 issue:4 pages:95-100 ispartof: location:United States status: published

In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OBJECTIVE: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. METHOD: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT (Milrod et al., 2016). Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. RESULTS: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. CONCLUSION: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

This article aims to articulate the use of trauma-focused psychodynamic psychotherapy (TFPP) for a 33-year-old U.S. Army veteran with posttraumatic stress disorder (PTSD) in a Veterans Affairs (VA) setting.The patient was treated with TFPP, a manualized brief psychotherapy provided as part of a pilot study. TFPP differs from traditional dynamic psychotherapies in its focus on symptoms of trauma and associated dynamics. The patient was seen for an initial 60-minute intake session and then for 16 50-minute sessions over 5.5 months at a VA medical center.Follow-up three months after termination of therapy indicated that the patient's panic disorder and PTSD symptoms remained much improved, although some rumination and difficulty focusing persisted.TFPP appears promising as shown with this patient and others in VA settings who have been treated with TFPP.

Chapter 6 consists of six subsections, describing the anxiety disorders treated with child and adolescent anxiety psychodynamic psychotherapy (CAPP). These include generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, panic disorder, agoraphobia and phobic avoidance, and (comorbid) posttraumatic stress disorder. Each section is organized as follows: the authors describe the phenomenology and diagnostic criteria, followed by the salient psychodynamic factors and conflicts. Each section concludes with treatment considerations, addressing transdiagnostic techniques, which apply to all anxiety disorders, and diagnosis-specific adaptations. Clinical vignettes are given for each anxiety disorder. A detailed table summarizes psychodynamic theory, target symptoms, and treatment strategies, followed by specific clinical approaches, rounding out variations of core fantasies and changes in techniques expected for each variant of the anxiety disorders.

Chapter 4 describes how to perform child and adolescent anxiety psychodynamic psychotherapy (CAPP) and includes clinical vignettes. Each phase is followed by a delineation of Tom’s treatment. The opening phase describes how the therapist’s listening and assessment of the material lead to a provisional psychodynamic formulation, which is verbalized to the youth. Typical dynamisms are separation anxiety; difficulties tolerating angry, aggressive, and ambivalent feelings; conflicted sexual fantasies; guilt; and ambivalence regarding independence. During the middle phase, therapist and patient collaboratively understand the central psychological conflicts identified and make adjustments to this formulation as needed. The goal is a deepening understanding of the meaning of the anxiety symptoms, with improvement in reflective functioning. The termination phase serves to review the recent changes and to revisit earlier symptoms, particularly if there is a rearousal of symptoms in which separation conflicts are experienced with the therapist. Adaptive and sensible autonomy-seeking is encouraged.

Child and adolescent anxiety psychodynamic psychotherapy (CAPP) is a new, manualized, tested, 24-session psychotherapy articulating psychodynamic treatment for youths with anxiety disorders. The book describes how clinicians intervene by collaboratively identifying the meanings of anxiety symptoms and maladaptive behaviors and communicating the emotional meanings of these symptoms to the child. The treatment is conducted from a developmental perspective, and the book contains clinical examples of how to approach youth of varying ages. The authors demonstrate that CAPP can help children and adolescents: • Reduce anxiety symptoms by developing an understanding of the emotional meanings of symptoms • Enhance the skill of reflection and self-observation of one’s own and others’ feelings and motivations (improvement in symptom-specific reflective functioning) • Diminish use of avoidance, dependence, and rigidity by recognizing how underlying emotions (e.g., guilt, shame, anger), as well as conflicted wishes can be tolerated and understood • Understand fantasies and personal emotional significance surrounding the anxiety symptoms to reduce symptoms’ magical, compelling qualities and impact on the child The manual provides a description of psychodynamic treatment principles and techniques and offers a guide to the opening, middle, and termination phases of this psychotherapy. The book contains chapters on the historical background of child psychodynamic psychotherapy, on developmental aspects of child psychotherapy, and on the nature of parent involvement in the treatment. This manual is intended to be used by clinicians from diverse therapy backgrounds, and it will appeal to the student reader as well as to the experienced clinician.

Child and adolescent anxiety psychodynamic psychotherapy (CAPP) follows psychoanalytic principles by addressing the unconscious meaning of the child’s symptoms, while employing a time-limited, twice-weekly frame, which affects technique. In Chapter 2, the authors illustrate how the therapist establishes a collaborative and empathic relationship with the child, identifies a central psychological dynamism early, and consistently refocuses on the presenting anxiety symptoms and the jointly identified psychological dynamisms. The authors describe variations in psychotherapeutic technique necessitated by the age-related capacities of the young patient. Important psychodynamic principles, such as transference, are described. Reflective functioning, which is the capacity to be reflective about one’s own mind and to envision mental states in others, is explained. Selective attention is paid to symptom-specific reflective functioning, which refers to the capacity to reflect on the specific anxiety symptoms and their meanings as an important mediator of change.

Chapter 7 concludes the manual with the case presentation of Marie’s treatment. Marie, who was introduced at the beginning of the manual, is a 14-year-old ninth-grader with anxious inhibitions arising from her history of being bullied. She presented with a two-and-a-half-year history of severe primary social anxiety disorder, with comorbid posttraumatic stress disorder, agoraphobia, and separation anxiety disorder, with episodes of dizziness and crying and inability to speak in any situation outside of her home or school classes. The authors describe how Marie’s treatment unfolded, the salient developments during the three phases of treatment, and how the particular use of understanding recurrent nightmares became a turning point in her treatment.

Chapter 1 acquaints the reader with child and adolescent anxiety psychodynamic psychotherapy (CAPP), a novel time-limited psychodynamic psychotherapy for children with anxiety disorders, which has undergone preliminary studies. CAPP’s unique feature is that it is focused on the individual meanings of the symptoms, rather than solely on behavioral and symptomatic change. CAPP works to help to reveal the meaning of the symptoms, increases the capacity to reflect, and actively engages the child patient in bringing about change. The literature is reviewed regarding the impact of anxiety disorders on the child and family, as well as the societal burden in terms of the significant health care costs. The authors elucidate the historical background of child psychodynamic psychotherapy and explain the background of CAPP as a developmentally modified version of panic-focused psychodynamic psychotherapy (PFPP), the only psychodynamic psychotherapy to meet evidence-based criteria for adults with anxiety disorders. Two patients, Marie and Tom, who will be followed throughout the book, are introduced. Chapter 1 concludes with an overview of the three phases of treatment.

Chapter 5 focuses on the nature and meaning of parent involvement in child and adolescent anxiety psychodynamic psychotherapy (CAPP). Most of CAPP is conducted with the therapist and child or teen alone. The importance of parent participation relates to the practical and natural developmental dependence of the child on the parent, as well as the importance of a solid therapeutic alliance with the parents, which is essential to sustain and maintain the treatment of the youngster. Separation anxious parents are sometimes conflicted about letting go of the child and allowing a relationship to develop with the therapist that largely excludes the parent. It is important for the therapist to be aware of such tendencies in parents so that they can be addressed when they occur and will not interfere with treatment. Specific guidelines are described regarding working with younger children and working with parents of teens.

Objective To compare cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), and applied relaxation training (ART) for primary DSM-IV panic disorder with and without agoraphobia in a 2-site randomized controlled trial. Method 201 patients were stratified for site and DSM-IV agoraphobia and depression and were randomized to CBT, PFPP, or ART (19-24 sessions) over 12 weeks in a 2:2:1 ratio at Weill Cornell Medical College (New York, New York) and University of Pennsylvania ("Penn"; Philadelphia, Pennsylvania). Any medication was held constant. Results Attrition rates were ART, 41%; CBT, 25%; and PFPP, 22%. The most symptomatic patients were more likely to drop out of ART than CBT or PFPP (P = .013). Outcome analyses revealed site-by-treatment interactions in speed of Panic Disorder Severity Scale (PDSS) change over time (P = .013). At Cornell, no differences emerged on improvement on the primary outcome, estimated speed of change over time on the PDSS; at Penn, ART (P = .025) and CBT (P = .009) showed greater improvement at treatment termination than PFPP. A site-by-treatment interaction (P = .016) for a priori-defined response (40% PDSS reduction) showed significant differences at Cornell: ART 30%, CBT 65%, PFPP 71% (P = .007), but not at Penn: ART 63%, CBT 60%, PFPP 48% (P = .37). Penn patients were more symptomatic, differed demographically from Cornell patients, had a 7.2-fold greater likelihood of taking medication, and had a 28-fold greater likelihood of taking benzodiazepines. However, these differences did not explain site-by-treatment interactions. Conclusions All treatments substantially improved panic disorder with or without agoraphobia, but patients, particularly the most severely ill, found ART less acceptable. CBT showed the most consistent performance across sites; however, the results for PFPP showed the promise of psychodynamic psychotherapy for this disorder. Trial registration ClinicalTrials.gov identifier: NCT00353470.

Objective The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive–behavioural treatment (CBT) manual were tested. Method Thirty-eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24-session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the structured clinical interview for DSM-IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory—short form. Results The higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence. Conclusions Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner message Patients' behavioural resistance to therapy may make it more difficult for cognitive–behavioural clinicians to adhere to a structured treatment protocol and more likely for them to borrow interventions from outside the CBT model. Patients' Axis II traits may make adherence to treatment CBT protocol more difficult, although whether this is true varies across therapists. Therapists' adherence to a structured protocol and borrowing from outside of the CBT model do not appear to be affected by disorder severity or Axis I comorbidity.

Introduction When a patient does not benefi t or has intolerable sideeff ects from an antidepressant or anxiolytic medication, the prescribing psychiatrist can rely on a range of evidence-based guideposts. Most clinicians probably feel familiar and comfortable with switching or augmenting medications and with the idea of sequential medication treatment algorithms. As Michael Thase noted in a JAMA Psychiatry editorial, the same does not hold for psychotherapies—although it should. Ignorance of whether or how to change psychotherapies is a major and persisting gap in psychiatric knowledge. We discuss this problem from clinical and research perspectives.

Objective Panic disorder (PD) is associated with significant personal, social, and economic costs. However, little is known about specific interpersonal dysfunctions that characterize the PD population. The current study systematically examined these interpersonal dysfunctions. Method The present analyses included 194 patients with PD out of a sample of 201 who were randomized to cognitive-behavioral therapy, panic-focused psychodynamic psychotherapy, or applied relaxation training. Interpersonal dysfunction was measured with the Inventory of Interpersonal Problems-Circumplex (Horowitz, Alden, Wiggins, & Pincus, 2000). Results Individuals with PD reported greater levels of interpersonal distress than that of a normative cohort (especially when PD was accompanied by agoraphobia), but lower than that of a cohort of patients with major depression. There was no single interpersonal profile that characterized PD patients. Symptom-based clusters (with vs. without agoraphobia) could not be discriminated on core or central interpersonal problems. Rather, as revealed by cluster analysis based on the pathoplasticity framework, there were 2 empirically derived interpersonal clusters among PD patients that were not accounted for by symptom severity and were opposite in nature: domineering-intrusive and nonassertive. The empirically derived interpersonal clusters appear to be of clinical utility in predicting alliance development throughout treatment: Although the domineering-intrusive cluster did not show any changes in the alliance throughout treatment, the nonassertive cluster showed a process of significant strengthening of the alliance. Conclusions Empirically derived interpersonal clusters in PD provide clinically useful and nonredundant information about individuals with PD.

Objective Given the chronic, episodic nature of panic disorder, it is important to examine long-term outcomes of patients who respond well to various psychotherapies. Method Out of 116 patients with DSM-IV panic disorder who evidenced a ≥ 40% reduction in panic and avoidance symptoms on the Panic Disorder Severity Scale (PDSS) after 12-14 weeks of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation training as part of a 2-site randomized controlled trial conducted between January 2007 and July 2012, 91 patients provided at least 1 PDSS datapoint during follow-up. Patients were assessed at each of the 12 following months using the PDSS, the Sheehan Disability Scale (SDS), and the Hamilton Depression Rating Scale (HDRS) and twice during the follow-up period with the Anxiety Disorders Interview Schedule. Results Patients with panic disorder who responded to 1 of 3 treatments maintained their gains on the PDSS, SDS, and HDRS with no differences by condition in rates of change over the follow-up period (all P values ≥ .20). Similarly, 57% of improved patients did not have a panic disorder diagnosis by the end of 1 year, regardless of the treatment received. No differences in rates of panic disorder diagnosis were found across treatment conditions at either 6 months or 12 months (all P values ≥ .78). Results should be interpreted in light of the fact that patients giving data at follow-up experienced lower symptom levels at treatment termination than those not providing data. Conclusions Improvement in any of the 3 treatments examined in this trial was largely maintained for a year following the end of therapy. Future treatment development could focus on factors to increase the level of response in the active phase of therapy. Trial registration ClinicalTrials.gov identifier: NCT00353470.

Objective To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients. Method Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS). Results Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment. Conclusions Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

Although widely used, the Hamilton Rating Scale for Depression (HRSD) and Hamilton Anxiety Rating Scale (HARS) discriminate poorly between depression and anxiety. To address this problem, Riskind, Beck, Brown, and Steer (J Nerv Ment Dis. 175:474-479, 1987) created the Reconstructed Hamilton Scales by reconfiguring HRSD and HARS items into modified scales. To further analyze the reconstructed scales, we examined their factor structure and criterion-related validity in a sample of patients with major depressive disorder and no comorbid anxiety disorders (n = 215) or with panic disorder and no comorbid mood disorders (n = 149). Factor analysis results were largely consistent with those of Riskind et al. The correlation between the new reconstructed scales was small. Compared with the original scales, the new reconstructed scales correlated more strongly with diagnosis in the expected direction. The findings recommend the use of the reconstructed HRSD over the original HRSD but highlight problems with the criterion-related validity of the original and reconstructed HARS.

Clinically significant separation anxiety disorder in childhood leads to adult panic disorder and other anxiety disorders. The prevailing pathophysiological model of anxiety disorders, which emphasizes extinction deficits of fear-conditioned responses, does not fully consider the role of separation anxiety. Pathological early childhood attachments have far-reaching consequences for the later adult ability to experience and internalize positive relationships in order to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation. Initially identified in attachment research, the phenomenon of separation anxiety is supported by animal model, neuroimaging, and genetic studies. A role of oxytocin is postulated. Adults, inured to their anxiety, often do not identify separation anxiety as problematic, but those who develop anxiety and mood disorders respond more poorly to both pharmacological and psychotherapeutic interventions. This poorer response may reflect patients' difficulty in forming and maintaining attachments, including therapeutic relationships. Psychotherapies that focus on relationships and separation anxiety may benefit patients with separation anxiety by using the dyadic therapist-patient relationship to recapture and better understand important elements of earlier pathological parent-child relationships.