Psychodynamic Therapy for Anxiety Disorders?

 

The commonly accepted wisdom in the field, backed by large amounts of research, is that cognitive behavioral therapy (CBT) in its various manifestations is the most effective treatment for anxiety and panic disorders. From the Veterans’ Administration to private and public clinics, therapies rooted in CBT such as exposure therapy, dialectical behavioral therapy, virtual reality, mindfulness, and EMDR are the treatment of choice for anxiety disorders. But quantitative research on psychodynamic therapy is growing, and as psychodynamic thinking continues to acquire the imprimatur of an empirically supported treatment, the enduring questions about the relative values of CBT and psychodynamic psychotherapy need to be once again considered.

The value of CBT should not be dismissed, especially in these times of increased emphasis on short–term costs and quick overt symptom reduction. The rise of short-term psychodynamic therapies such as Interpersonal Psychotherapy deliver similar benefits and results as do CBT (Stangier et al., 2011; Markowitz et al., 2014; Milrod 2007), in the first controlled clinical trial of a psychodynamic therapy for any DSM-IV panic disorder, compared a short-term psychodynamic treatment to a CBT-oriented applied relaxation training. The 24-session, 12-week psychodynamic therapy successfully treated 73 percent of the subjects, whereas 39 percent of the applied relaxation training group met the criteria for response. Milrod’s study also had a low attrition rate, and clinical trials of anxiety disorders generally have a high attrition rate: only two of the 26 subjects dropped out, compared to the relaxation training group’s attrition rate of 8 out of 23. In Milrod’s psychodynamic therapy, clients were encouraged to explore such things as the personal meanings they attributed to their attacks and how the attacks were related to underlying dynamics such as separation problems, difficulties with autonomy, and conflicted anger. These issues were explored in the context of the therapeutic relationship.

Milrod et. al. (2014) later explored the relationship between separation anxiety developed in childhood and adult anxiety disorders. Citing Manicavasagar et al. (2010), they note that 75% of adults with anxiety disorders who seek treatment at anxiety disorders clinics reported having had separation anxiety disorder as children. Milrod et al. surmise both a genetic and psychosocial developmental trajectory from childhood separation anxiety to adult anxiety disorders. They point to Roberson-Nay et al.s (2012) longitudinal study of twins suggesting a common genetic pathway to panic disorders. Whether the trajectory from childhood separation anxiety to adult anxiety disorders is more psychological or biological—there is more than enough research on the two to suggest that it is both—this goes a long way toward explaining the high treatment dropout rate for anxious clients. Anxiety disorders that have developed from separation anxiety, Milrod et al (2014) note, can create “a global sense of inadequacy and incompetence that can undermine psychiatric treatments of any modality” (p 38). This makes it imperative for the therapist to “consistently focus on separation anxiety and the distortions it evokes to facilitate its verbal articulation” (p 38). In other words, they argue, a mere focus on the behavioral symptoms will have limited success and a high drop-out rate. They particularly note that the use of electronic communication may support rather than alleviate the underlying separation anxiety. This seems an especially important point because there is a growing use of CBT treatments that utilize smart phone apps to treat anxiety.

Behavioral therapies for anxiety focus on extinguishing anxiety symptoms, whereas psychodynamic therapies for anxiety focus on relationships, especially between therapist and client, and the effects associated with anxiety. Psychodynamic therapies, Milrod et al (2014) write, “actively address improving patients’ capacity for reflection and helping them to recognize and tolerate emotional responses and perceived dangers surrounding attachment. Therapists attuned to patients’ separation fears may detect them in the transference or in outside relationships and can use dynamic or interpersonal approaches to articulate and help patients to better understand them, thereby decreasing their intensity” (p 38).

REFERENCES

Manicavasagar V, Marnane C, Pini S, Abelli M, Rees S, Eapen V, Silove D. (2010). Adult separation anxiety disorder: a disorder comes of age. Current Psychiatry Reports 12:290–297

Milrod, Barbara (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164 (2), 265-272

Milrod, B.,Markowitz, J.D.,, Gerber, A.J., Cyranowski,J., Altemus, M., Shapiro, T., Hofer, M. & Glatt, C (2014). Childhood separation anxiety and the pathogenesis and treatment of adult anxiety. American Journal of Psychiatry, 171, 34-43

Roberson-Nay R, Eaves LJ, Hettema JM, Kendler KS, Silberg JL (2012). Childhood separation anxiety disorder and adult onset panic attacks share a common genetic diathesis. Depression & Anxiety 29:320–327

Stangier U1, Schramm E, Heidenreich T, Berger M, Clark DM (2011). Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: a randomized controlled trial. Archives of General Psychiatry 68 (7):692-700