Anterior hippocampal volume predicts affect-focused psychotherapy outcome.

BACKGROUND: The 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)]. METHODS: Thirty-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. RESULTS: Baseline 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. CONCLUSIONS: This 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.

Mentalizing in Interpersonal Psychotherapy.

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.

Twelve-Month Outcomes Following Successful Panic-Focused Psychodynamic Psychotherapy, Cognitive-Behavioral Therapy, or Applied Relaxation Training for Panic Disorder.

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.

Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension.

OBJECTIVE: We tested the relation of perceived criticism (PC) from a parent or spouse/romantic partner to outcome of psychotherapy for panic disorder (PD). METHOD: Participants were 130 patients with PD (79% with agoraphobia) who received 24 twice-weekly sessions of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation therapy. Patients were predominantly White (75%), female (64%), and non-Hispanic (85%). At baseline, Week 5 of treatment, termination, and at 6- and 12-month follow-up, patients rated PC from the relative with whom they lived. Independent evaluators assessed the severity of PD at baseline, Weeks 1, 5, and 9 of treatment, termination, and the 2 follow-up points. Data were analyzed with piecewise (treatment phase, follow-up phase) latent growth curve modeling. RESULTS: The latent intercept for PC at baseline predicted the latent slope for panic severity in the follow-up (p = .04) but not the active treatment phase (p = .50). In contrast, the latent intercept for PD severity at baseline did not predict the latent slope on PC in either phase (ps ≥ .29). Nor did the slopes of PC and PD severity covary across treatment (p = .31) or follow-up (p = .13). Indeed, PC did not change significantly across treatment (p = .45), showing the stability of this perception regardless of significant change in severity of patients' PD (p < .001). CONCLUSIONS: Because PC predicts worse long-term treatment outcome for PD, study findings argue for interventions to address perceived criticism in treatment. (PsycINFO Database Record

Psychotherapies for Panic Disorder: A Tale of Two Sites.

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.

Are there subtypes of panic disorder? An interpersonal perspective.

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.

A study demonstrating efficacy of a psychoanalytic psychotherapy for panic disorder: implications for psychoanalytic research, theory, and practice.

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.

Does interpersonal loss preceding panic disorder onset moderate response to psychotherapy? An exploratory study.

BACKGROUND: Little research has addressed moderators of treatment outcome for anxiety disorders, and none has considered interpersonal loss as a predictor of outcome. PURPOSE: To examine the effect of interpersonal loss events within the 6 weeks preceding panic disorder onset as a moderator of outcome in a randomized controlled trial of Panic-Focused Psychodynamic Therapy (PFPP) and Applied Relaxation Therapy (ART). Researchers hypothesized that such loss events would predict better outcome in PFPP but would not affect ART outcome. METHOD: Forty-nine subjects with panic disorder were randomly assigned to a 12-week course of PFPP or ART. Independent raters blinded to treatment condition and study hypotheses rated subjects on the Panic Disorder Severity Scale (PDSS) and Sheehan Disability Scale. Exploratory analyses assessed between-group effect size for PFPP and ART following standard moderator analytic procedures. The trial was conducted between February 2000 and January 2005. RESULTS: Three quarters of subjects reported a narrowly defined interpersonal loss (LOSS) in the 6 weeks preceding panic disorder onset. These subjects had a mean (SD) duration of panic disorder of 8.2 (9.5) years. PFPP was more efficacious than ART, but LOSS did not moderate PFPP outcome. An unexpected finding was that LOSS moderated ART outcome: subjects without LOSS showed no response to ART (PDSS mean (SD) change score = 0.00 [2.90]), whereas LOSS had a pre-post mean (SD) change score of 4.29 (5.60). Neither examination of potential confounding variables nor sensitivity analyses of assumptions regarding attrition altered these findings. CONCLUSIONS: Interpersonal loss events preceding onset of panic disorder were more common even than in prior studies. These losses moderated outcome in ART, a therapy that does not focus on such losses. Implications and the need for future research before incorporating these findings into clinical practice are discussed. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00128388.

Do comorbid personality disorders moderate panic-focused psychotherapy? An exploratory examination of the American Psychiatric Association practice guideline.

OBJECTIVE: The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome. METHOD: Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005. RESULTS: Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity. CONCLUSIONS: Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT00128388.

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder.

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.