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Psychoanalytic approaches, although still extensively used by practitioners, have been marginalized in treatment guidelines partly because of limited efficacy research. In recent years, several manualized psychodynamic approaches have been developed that target specific problems or disorders, which can be referred to generally as problem-focused psychodynamic psychotherapies. These treatments offer modified psychodynamic techniques to address dynamics associated with particular disorders and can be used for systematic outcome studies. For example, one of these, panic-focused psychodynamic psychotherapy, has demonstrated efficacy in the treatment of panic disorder. The manuals for these psychotherapies emphasize comprehensibility for training purposes and are more readily transportable to the public health sector. Extensive research will be needed to ascertain which psychotherapies are most effective for various patients and conditions over the short and long term.

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.

Over the last 30 years, several disorder-focused psychodynamic psychotherapies have been developed to directly address specific problem areas. This chapter will describe depression-focused psychodynamic psychotherapy as one form of these interventions. Consistent with these approaches, the chapter will describe a core psychodynamic formulation for depression, including particular self and other representations, intrapsychic conflicts, and defenses. The formulation posits a core vulnerability that can lead to vicious cycles involving (1) angry reactions to narcissistic injury and (2) a compensatory idealization that then triggers subsequent intense disappointment in self and others. The chapter will then provide an overview of how to address these vulnerabilities using psychodynamic techniques modified for treatment of depressive symptoms.

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...

Psychoanalysts have generally avoided discussion of psychoeducational interventions in the context of psychodynamic psychotherapy, despite education being a component of many psychoanalytic techniques. This wariness stems from Freud's early concerns about interventions that could be deemed "suggestion," and a misunderstanding of various aspects of neutrality, including viewing psychoeducational comments as over-gratifying or siding with the ego. Although potential pitfalls exist, the authors review clinical evidence and research that indicate the value of psychoeducational approaches for engaging patients in psychodynamic psychotherapy, considering alternative treatments, providing a psychodynamic formulation, and enhancing the therapeutic alliance. In this context there has been increasing inclusion of psychoeducational interventions in clinical descriptions and manuals of psychodynamic psychotherapy. Various aspects of psychoeducation are described, including education about the patient's problems, how the treatment works, how the mind works, relevant information from other areas of psychology and neuroscience, and how the world works. A case example is provided that further demonstrates the value of psychoeducation in the clinical setting.

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.

One of the shibboleths of psychoanalysis is that treatment should not target behavioral change, focusing instead on gaining insight and the therapeutic relationship (Freud, 1917; 1923; Gabbard, 2014; Greenson, 1967). Such an approach is believed to be accompanied by disruptions of exploration or problematic distortions of the transference (Freud, 1917; 1923; Gabbard, 2014; Greenson, 1967). However, ignoring behavioral change can put patients at increased risk for stalemates in treatment and persistent problematic behaviors that interfere with improvement and impair relationships. This article suggests that rather than being at odds or disruptive, efforts at behavioral change can be part of the development and employment of a psychodynamic formulation, and can be used to enhance self-understanding and exploration of the transference. Psychoanalytic approaches provide strategies for behavioral change not included in other psychotherapeutic treatments. This article describes a variety of ways in which efforts at behavioral change can be integrated with and enhanced by psychodynamic exploration.

Somatization is the experience and expression of psychological distress through bodily symptoms. Somatization can be conceptualized as an emotional state that has not been represented symbolically or as a defense against intolerable emotions and fantasies. Bodily concerns can also function as a means of seeking responsiveness from others. Alexithymia refers to a difficulty identifying and symbolizing emotional states that has been found to be associated with somatization. When functioning as a defense, a focus on the body can be used to avoid frightening or intolerable feelings and fantasies, or to ward off aggressive fantasies by viewing oneself as physically damaged. Systematic studies have demonstrated the presence of the defense of somatization in mood disorders, particularly anxiety and panic disorders. In treating anxiety disorders, the therapist helps the patient to determine the nature of emotions and fantasies that the patient is defending against, particularly fears and conflicts surrounding anger and separation.

Panic-Focused Psychodynamic Psychotherapy (PFPP) is a 24-session, twice-weekly treatment that has been manualized and has demonstrated efficacy in a randomized controlled trial in the treatment of panic disorder. The treatment has recently been extended to address additional DSM-IV anxiety disorders and Cluster C personality traits and disorders. The manualized approach identifies a set of dynamisms that contribute to panic onset and persistence involving intrapsychic conflicts about separation, autonomy, anger, and guilt. The treatment aims at increasing patients' recognition and understanding of these dynamics through exploration of the meaning and circumstances of their panic attacks, related intrapsychic dynamics, developmental factors, and the transference. The termination of treatment is particularly important in working through conflicts surrounding separation and autonomy. This article describes the formulation and psychotherapeutic approach in greater depth, and a case example is provided. We the...

Panic-focused psychodynamic psychotherapy (PFPP) is a 24-session, twice-weekly (12 weeks), manualized psychoanalytic psychotherapy with demonstrated preliminary efficacy for panic disorder (PD).1,2 Given the substantial morbidity and the health care utilization of the PD population,3,4 coupled with the sizable proportion of such patients who do not respond (or respond inadequately) to alternate treatments (cognitive-behavioral therapy [CBT] and drug therapy),5–7 PFPP may offer clinicians an additional tool for their therapeutic armamentarium. It may also facilitate a rapprochement between academic psychiatry and psychodynamic perspectives, and a reassessment of the role of psychodynamic therapy as part of the educational experience of residents in training—an experience that has diminished over two decades.

A contemporary perspective on psychotherapy and pharmacotherapy views both treatments as somatic in nature. Abandoning Cartesian dualism frees the clinician to consider therapeutic options based on the best available evidence rather than falsely dichotomizing approaches as biological or psycho- logical. Evidence-based medicine is a helpful though limited paradigm upon which to base treatment decisions. Instead, clinicians should strive for an evi- dence-informed approach that is patient centered. This approach is illustrated in relation to depressive illness where moderators of outcome are examined (illness severity, history of trauma, personality disorders, patient preference) that will influence clinical recommendations on combining treatment. Psycho - therapy is increasingly proving to be a valuable therapeutic modality across the severity spectrum, a finding at odds with current treatment practices. The early antagonism toward the use of medication among dynam- ic psychiatrists in the dawning era of biological psychiatry in the late 1950s and 1960s (see Ostow, 1962 for a notable exception) has given way to a general acceptance of the value of medication and combined treatment. Even among psychoanalysts, the use of medication is com- monplace reflecting a sea change from an earlier generation (Donovan & Roose, 1995). Dynamic psychiatry strives to create a viable balance by incorporating the legitimate place of pharmacotherapy (and related advances in brain science) into its theoretical and clinical framework. However, numerous influences within psychiatry and the broader cul

Although the need for psychoanalytic research is increasingly acknowledged, many psychoanalysts remain resistant to the performance and findings of this research. Objections to research include a continuing mistrust of research tools and approaches, combined with a belief in the effectiveness of psychoanalytic treatments based on clinical lore and individual experience. Furthermore, as psychoanalytic literature continues to function within its own separate domain, even well-read psychoanalysts can be sequestered from central scientific conversations occurring in the larger literature about mental health. In part due to these factors, few adequate studies of psychoanalytic treatment approaches have been performed. The lack of efficacy research has added to the marginalization of psychoanalytic treatments. Fortunately, in recent years groups of clinicians and researchers have begun to study psychoanalytic treatments, particularly approaches to specific disorders. In this context, this issue provides a welco...

SummaryA series of psychoanalytic theorists and clinicians have suggested that conflicts about anger play a central role in the development of depression. Research data have supported the notion that patients struggle with the experience and expression of angry feelings. Anger in people with depression often stems from narcissistic vulnerability, a sensitivity to perceived or actual loss or rejection. These angry reactions cause intrapsychic conflicts through the onset of guilt and the fear that angry feelings will disrupt relationships. These conflicts lead to anger being directed inwards, further lowering self-esteem, creating a vicious cycle. Defence mechanisms that are triggered, including passive aggression, reaction formation, denial and identification with the aggressor, are ineffective at managing these conflicts and further prevent the appropriate expression of anger. This article discusses how to identify and detoxify angry feelings and fantasies using a psychodynamic approach.

Systematic research on psychoanalytic treatments has been limited by several factors, including a belief that clinical experience can demonstrate the effectiveness of psychoanalysis, rendering systematic research unnecessary, the view that psychoanalytic research would be difficult or impossible to accomplish, and a concern that research would distort the treatment being delivered. In recent years, however, many psychoanalysts have recognized the necessity of research in order to obtain a more balanced assessment of the role of psychodynamic psychotherapy and psychoanalysis in a contemporary treatment armamentarium, as well as to allow appropriate evaluation and potentially greater acceptance by the broader mental health and medical communities. In this context, studies were conducted of a psychodynamic treatment, Panic-Focused Psychodynamic Psychotherapy (PFPP), initially in an open trial and then in a randomized controlled trial (RCT) in comparison with a less active treatment, Applied Relaxation Training (ART; Cerny et al. 1984), for adults with primary DSM-IV panic disorder. The results of the RCT demonstrated the efficacy of PFPP in treating panic disorder, and also demonstrated that a psychoanalytic treatment can be systematically evaluated in a mode consistent with the principles of evidence-based medicine. Two specific features of the methodology, the development of the treatment manual and the operationalization of the adherence instrument, both core building blocks of contemporary psychotherapy outcome research, and their implications for psychoanalytic research are discussed in greater depth. The theoretical, clinical, and educational implications of the PFPP studies are elaborated, and suggestions are made for pursuing further outcome research of psychoanalytic treatments.

The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder.This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure.Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results.Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.

Separation anxiety, long an area of interest for psychoanalysts, has been included in DSM-5 among general “anxiety disorders” that span across age groups. The syndrome of separation anxiety has been shown to correlate with nonresponse to treatments for anxiety and mood disorders (Milrod et al. 2014). It is therefore of public health importance to develop targeted treatments for this syndrome. Some psychoanalysts have suggested that brief psychoanalytic interventions may be of particular value in addressing separation anxiety. Our clinical work with patients with anxiety disorders with high levels of separation anxiety indicates that they have such intense anger and ambivalence in fraught intimate relationships that they feel stuck and helpless, almost eliminating more positive feelings. This ambivalence and associated unconscious conflicts inevitably emerge in the therapeutic relationship and can threaten to disrupt treatment efforts. We propose a set of focused psychodynamic psychotherapeutic interventions to address separation anxiety, developed as part of Panic-Focused Psychodynamic Psychotherapy–eXtended Range (PFPP-XR; Busch et al. 2012). We present a case from our research study of treatment nonresponders with anxiety disorders and separation anxiety. The patient was successfully treated with PFPP-XR in a 21-session treatment.

Clinically significant separation anxiety [SA] has been identified as being common among patients who do not respond to psychiatric interventions, regardless of intervention type (pharmacological or psychotherapeutic), across anxiety and mood disorders. An attachment formation and maintenance domain has been proposed as contributing to anxiety disorders. We therefore directly determined prevalence of SA in a population of adult treatment non-responders suffering from primary anxiety. In these separation anxious nonresponders, we pilot-tested an SA-focused, attachment-based psychotherapy for anxiety, Panic-Focused Psychodynamic Psychotherapy-eXtended Range [PFPP-XR], and assessed whether hypothesized biomarkers of attachment were engaged. We studied separation anxiety [SA] in 46 adults (ages 23–70 [mean 43.9 (14.9)]) with clinically significant anxiety symptoms (Hamilton Anxiety Rating Scale [HARS] ≥ 15), and reporting a history of past non-response to psychotherapy and/or medication treatments. Thirty-seven (80%) had clinically significant symptoms of separation anxiety (Structured Clinical Interview for Separation Anxiety Symptoms [SCI-SAS] score ≥8). Five of these subjects completed an open clinical trial of Panic Focused Psychodynamic Psychotherapy eXtended Range [PFPP-XR], a 21–24 session, 12-week manualized attachment-focused anxiolytic psychodynamic psychotherapy for anxiety. Patients improved on “adult threshold” SCI-SAS (current separation anxiety) (p = .016), HARS (p = 0.002), and global severity, assessed by the Clinical Global Impression Scale (p = .0006), at treatment termination. Salivary oxytocin levels decreased 67% after treatment (p = .12). There was no significant change in high or low frequency HRV after treatment, but change in high frequency HRV inversely correlated with treatment change in oxytocin (p < .02), and change in low frequency HRV was positively associated with change in oxytocin (p < .02). SA is surprisingly prevalent among non-responders to standard anti-anxiety treatments, and it may represent a novel transdiagnostic target for treatment intervention in this population. Anxiety and global function improved in a small trial of a brief, manualized, attachment-focused psychodynamic psychotherapy, potentially supporting the clinical relevance of attachment dysfunction in this sample. The large decrease in oxytocin levels with treatment, although not statistically significant in this very small sample, suggests the need for further study of oxytocin as a putative biomarker or mediator of SA response. These pilot data generate testable hypotheses supporting an attachment domain underlying treatment-resistant anxiety, and new treatment strategies.

This study identified psychotherapeutic processes that relate meaningfully to psychotherapeutic outcome for patients with panic disorder undergoing Panic-Focused Psychodynamic Psychotherapy (PFPP) (Milrod et al., 1997). Subjects were 21 patients who participated in an open clinical trial of PFPP (Milrod et al., 2000; Milrod et al., 2001). The Interactive Process Assessment (IPA) (Klein, Milrod, and Busch, 1999), a process measure developed specifically to identify the process of PFPP, was used. Process-outcome relationships were calculated between process factors at early, mid, and late treatment and outcome measures at termination. Results showed that the therapist's focus on the transference late in treatment was associated with a decrease in panic symptoms. Transference focus early in the treatment, however, was correlated with an increase in related symptomatology, as measured by the HAM-A and SDS. It was unclear from the present study how focusing on panic symptomatology affected the treatment. This ...

Somatic or emotional experience that has not been symbolically represented, referred to as unmentalized experience, has been given an increasingly prominent role in understanding psychopathology. Panic and anxiety disorders provide a useful model for exploring these factors, as the affective and bodily symptoms can be understood in part as unmentalized experience. The authors explore models of Freud's actual neurosis, Marty and DeM'uzan's pensee operatoire, Klein's unconscious fantasy, Bion's alpha function, Bucci's multiple code system, and relational models to describe how somatic and affective experiences can be translated into symbolic representations, and what factors can interfere with these processes. Approaches to unmentalized aspects of panic and anxiety include symbolizing somatic symptoms, identifying emotional states, and identifying contextual and traumatic links to symptoms.

The psychoanalytic community increasingly recognizes the importance of research on psychoanalytic treatments, yet a significant number of psychoanalysts continue to believe that research is either irrelevant to psychoanalysis or impossible to accomplish. Psychoanalysts who accept the value of research express concern that intrusions required by research protocols create significant distortions in the psychoanalytic process. The authors, all psychoanalysts, are studying the outcome of a brief (twenty-four-session) psychodynamic treatment of panic disorder. They report their experiences and struggles with the intrusions of videotaping, working with a treatment manual, and time-limited treatment. This research process required them to question old beliefs and to confront feelings of disloyalty toward their analytic training and identity, particularly with regard to keeping a “clean field” and routinely performing long-term analysis of character. The therapists' psychoanalytic knowledge, however, emerged as crucial for them in managing specific research constraints. Despite concerns about providing inadequate treatment, therapists were found to engage patients with psychoanalytic tools and focus in vibrant and productive therapies that led to significant improvements in panic symptoms and associated quality of life. The authors suggest that psychoanalysts have been overestimating the potential damage of research constraints on psychoanalytic process and outcome.

This article describes a course, Clinical Research in Psychotherapy, taught to PGY-3 residents at the New York Presbyterian Hospital-Weill Cornell Medical College. The course addresses existing research in outcome and process in psychotherapy, concepts important in research design, and assessment of results of psychotherapy research. It also explores how knowledge of research can enhance clinical practice. The authors believe that teaching psychotherapy research to residents will aid the development of a generation of clinicians who can best recognize the value of a psychodynamic approach for patients.

York, NY I 0021. lasted for 20 minutes and then gradually abated over the better part of an hour. Ms. A did not think of her panic as a reason for seeking psychiatric treatment. She did not have agoraphobia but lived with a chronic, vague sense of severe anxiety, accompanied by the fantasy that she was “doomed.” She had no specific phobias. The symptom that caused Ms. A the most distress was her chronic difficulty negotiat. ing relationships with others. Beginning with her earliest relationships with her parents and older sister in childhood, Ms. A found herself in interpersonal situations in which she felt abused and demeaned, either emotionally or physically. In high school and college she had often felt belittled by friends and boyfriends. Currently, these issues recurred in the context of her relationship with her fianc#{233} and her interactions with colleagues at graduate school. In the course of these stormy relationships, Ms. A would become so agitated and panicked that she was often violent. In the middle of fights with her fianc#{233}, for example, she would find herself hitting him and running out of the apartment dressed in insufficient clothing in the middle of the night. She had no vegetative symptoms. She had no history of depression, mania, psychosis, or substance abuse. She had never been suicidal. Ms. A’s medical history was considered noncontributory.

This manual presents a carefully researched, detailed psychodynamic treatment program for the alleviation of a transdiagnostic range of primary Axis I anxiety disorders, including panic disorder, generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, and related psychological problems. First exploring the principles of psychodynamic theory and formulation, the authors then present a three-phased process of Panic Focused Psychodynamic Psychotherapy-Extended Range (PFPP-XR): initial evaluation, interpretation of central conflicts and defense mechanisms, and termination. Each phase is discussed in depth and relies on central case illustrations to demonstrate techniques and results. A subsequent chapter explores how to address complex issues that may arise during the course of treatment. Altogether, this manual not only provides a demonstrated, adaptable approach for anxiety disorders, but also clearly embodies a spirit of research and empiricism heretofore rare in psychodynamic psychotherapies, with an eye toward future development.

OBJECTIVE: This report contains preliminary data from an open trial of brief psychodynamic psychotherapy for panic disorder. METHOD: Fourteen patients with primary DSM-IV panic disorder completed a 24-session, twice-weekly course of psychodynamic psychotherapy. Other psychiatric treatment was not permitted throughout the 12-week treatment period and the 6-month follow-up. Symptoms were assessed at baseline, treatment termination, and 6-month posttermination follow-up (40 weeks). RESULTS: Statistically significant, clinically meaningful improvements appeared in panic, depression, anxiety, and functional impairment both at treatment termination and at 6-month follow-up. CONCLUSIONS: Psychodynamic monotherapy can be used successfully to retain and treat patients with panic disorder. Psychodynamic interventions warrant further study for patients with panic disorder.

Social anxiety disorder is a severe psychiatric syndrome that results in significant suffering and impairment in psychosocial function (1, 2) (this volume, chapter by Baldwin and Buis). Many theoretical models exist to describe the causes of this disorder. Although psychoanalysts have developed several theoretical models of the development of anxiety, they have rarely focused on specific anxiety disorders as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (3). More systematic assessment of psychological factors and the development of therapeutic approaches to specific psychiatric syndromes has occurred only in recent years and remains outside mainstream psychoanalysis.

Recent surveys suggest that collaborations between psychiatrists acting as medication consultants and therapists providing psychotherapy are an increasingly common form of treatment. Complex transference and countertransference reactions can arise in these "therapeutic triangles." Risks include splitting by the patient, conflicts between the two practitioners, and premature termination of either the psychotherapy or pharmacotherapy. The authors discuss typical transference and countertransference reactions that can lead to these problems and present case examples of productive and unproductive collaborative efforts. The authors describe a collaborative approach based on mutual respect, trust, and openness that, along with an awareness of typical transference and countertransference issues, can increase the likelihood of a positive treatment outcome.

Psychodynamic factors have rarely been systematically studied in panic disorder, despite indications that these factors may be important in the understanding and treatment of panic. This is a report of a study using the Defense Mechanism Rating Scale to test the hypothesis that patients with panic disorder utilize particular defense mechanisms: reaction formation, undoing, and displacement. The use of defense mechanisms in 22 patients with primary panic disorder was compared with that of 22 patients with primary dysthymic disorder, based on Defense Mechanism Rating Scale ratings of psychodynamic interviews of these patients. Panic subjects scored significantly higher than dysthymics on the defenses of reaction formation and undoing, but not on the defense of displacement. The defense mechanisms found are consistent with a proposed psychodynamic formulation for panic disorder that emphasizes the panic patient's difficulty in tolerating angry feelings toward significant others. Knowledge of these defense mechanisms can be useful for various treatment approaches in panic disorder.