How treating psychoanalysts respond to psychotherapy research constraints.

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.

Oedipal dynamics in panic disorder.

Both research and clinical work have revealed factors that can lead to the onset and persistence of panic disorder. Preoedipal conflicts intensify the danger of oedipal longings for panic patients. Competition with the same-sex parent is linked with angry preoedipal fantasies and associated fears of disruption in attachments. Fantasies or actual successes can thus trigger panic episodes. Regression to a helpless, dependent state such as panic defends against the danger of aggressive, competitive fantasies and actual achievements. However, the regressive state can also be experienced as dangerous, and can be linked with frightening homosexual fantasies. A reactive aggressive oedipal stance can sometimes result, triggering escalating turmoil. The panic episode serves a series of compromise formations in dealing with these conflicted wishes.

Theory and technique in psychodynamic treatment of panic disorder.

The authors elaborate psychodynamic factors that are relevant to the treatment of panic disorder. They outline psychoanalytic concepts that were employed to develop a psychodynamic approach to panic disorder, including the idea of unconscious mental life and the existence of defense mechanisms, compromise formations, the pleasure principle, and the transference. The authors then describe a panic-focused psychodynamic treatment based on a psychodynamic formulation of panic. Clinical techniques used in this approach, such as working with transference and working through, are described. Finally, a case vignette is employed to illustrate the relevance of these factors to panic disorder and the use of this treatment.(The Journal of Psychotherapy Practice and Research 1999; 8:234-242)

An empirical study of defense mechanisms in panic disorder.

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.

Treatment by a psychotherapist and a psychopharmacologist: transference and countertransference issues.

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.

A psychodynamic model of panic disorder.

Current psychiatric research on panic disorder and its treatment are heavily influenced by neurobiological and cognitive-behavioral models rather than psychodynamic propositions, and psychodynamic treatment is generally considered to be of little benefit in amelioration of symptoms. However, because neither of the current models fully explains the clinical psychopathology, etiology, or pathogenesis of panic disorder, there is a need for further model building. The authors suggest that a psychodynamic approach may add to the understanding of patients with panic disorder. They base their psychodynamic formulation on pilot interviews with nine patients with panic disorder, published reports of psychological characteristics of patients with panic disorder, and data from infant and animal research on temperament. Interview results included the following: 1) all of the patients described themselves as fearful, nervous, or shy as children, 2) they remembered their parents as angry, frightening, critical, or controlling, 3) they frequently indicated discomfort with aggression, 4) most described chronic feelings of low self-esteem, 5) their spouses were characterized as passive, kind, and nonaggressive, and 6) stressors associated with frustration and resentment preceded the onset of panic. The authors propose a model in which inborn neurophysiological irritability predisposes to early fearfulness. Exposure to parental behaviors that augment fearfulness results in disturbances in object relations and persistence of conflicts between dependence and independence, which predispose to fears of feeling trapped, suffocated, and unable to escape and/or feeling alone and unable to get help. Catastrophic fears of helplessness in the face of suffocation or abandonment are easily accessible.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of two adjunctive treatment strategies in acute mania.

A benzodiazepine-neuroleptic adjunctive treatment strategy in a cohort of acutely manic patients was compared with standard neuroleptic adjunctive treatment in a matched sample treated in the same hospital. Thirty newly hospitalized manic patients receiving low-dose neuroleptic (310 mg/day chlorpromazine equivalents) and benzodiazepines (1.6 mg/day lorazepam equivalents) were compared, retrospectively, with 30 statistically similar patients receiving standard dose neuroleptic adjunctive treatment (590 mg/day chlorpromazine equivalents; 0.09 mg/day lorazepam equivalents). The benzodiazepine-neuroleptic-treated group demonstrated significantly fewer seclusion and restraint episodes (p less than .05) and were comparable on other parameters. Treatment with the benzodiazepine-neuroleptic combination may lead to fewer inpatient complications than standard neuroleptic treatment alone.

The influence of myo-inositol on phosphatidylglycerol synthesis by rat type II pneumonocytes.

Type II pneumonocytes isolated from adult rat lung were incubated in a serum-free medium containing [14C]glycerol and the incorporation of 14C into glycerophospholipids was measured. After 24 h, more than 80% of the 14C incorporated into total lipids or into phosphatidylcholine and approx. 90% of the 14C incorporated into phosphatidylglycerol after 24 h was recovered in the glycerophosphoester moieties of these molecules. Supplementation of the incubation medium with foetal-bovine serum (10%, v/v) did not alter the incorporation of [14C]glycerol by type II pneumonocytes after 24 h into either a total lipid extract or phosphatidylcholine. In the presence of foetal-bovine serum, however, the incorporation of 14C into phosphatidylglycerol was decreased and the incorporation of 14C into phosphatidylinositol was increased. In the absence of foetal-bovine serum, the incorporation of 14C into phosphatidylglycerol was decreased progressively as the concentration of myo-inositol in the incubation medium was increased. The range of concentration (0.04-0.50 mM) over which myo-inositol had the greatest influence on [14C]glycerol incorporation into phosphatidylglycerol by type II pneumonocytes in vitro encompassed the concentration range measured in foetal-rat serum late in gestation. At 4 days before birth, the concentration of myo-inositol in foetal-rat serum was 0.36 mM and decreased to 0.23 mM 1 day before birth. The concentration of myo-inositol in adult rat serum increased from 0.03 mM to 0.06 mM during pregnancy. Isolated rat type II pneumonocytes were found to take up myo-inositol by a saturable process. A half-maximal rate of myo-inositol uptake occurred at a concentration of myo-inositol of 0.29 mM. The results of this investigation are consistent with the hypothesis that late in gestation there is a decreasing availability of myo-inositol to the foetal lungs and that this favours the biosynthesis of phosphatidylglycerol for surfactant at the expense of phosphatidylinositol biosynthesis.