Short-Term Group Therapy for Complicated Grief: The Relationship Between Patients’ In-Session Reflection and Outcome

Objective: The objective of the present study was to examine the nature of patients’ work in two types of short-term group psychotherapy. The study sought to investigate the relationship between patients’ psychodynamic work versus supportive work in group psychotherapy and treatment outcome at termination and at 6-month follow-up. Psychodynamic work refers to reflection regarding intrapsychic motivations, defenses, and relational patterns, and supportive work refers to practical problem solving. Method: Participants were 110 patients who completed two forms of group therapy for complicated grief: interpretive therapy and supportive therapy. Two types of patients’ in-session activity—psychodynamic work and supportive work—were rated by group therapists in both treatments. Pre-post and follow-up outcome domains included general symptoms, grief symptoms, and life dissatisfaction/severity of target objectives. Results: There was no significant difference in the nature of patients’ therapeutic work between interpretive and supportive groups. Psychodynamic work was associated with pre-post improvement in grief symptoms. Psychodynamic work was also associated with further improvement in grief symptoms at 6-month follow-up, along with improvement in broader symptom domains. Supportive work was not associated with any pre-post or follow-up benefit. Conclusion: The findings provide evidence that psychodynamic work—focused on the development of insight and self-reflection—in group psychotherapy can contribute to further benefit after the completion of treatment. This finding cut across two approaches to short-term group therapy for complicated grief, suggesting that it may reflect a general curative mechanism of group treatments.     

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.     

Treating panic disorder: a psychotherapeutic case

Panic attacks are a common complaint of patients seeking psychiatric care. Treatment options for panic disorder include both medications and psychotherapy, either alone or in combination. Psychodynamic psychotherapy can be very effective in treating panic disorder, yet in recent years, psychiatric residency training has emphasized a medical model over teaching psychotherapy. In this article, we will use a composite case to illustrate how psychodynamic psychotherapy can be utilized to treat panic disorder in such a way that is rewarding for both the patient and the psychiatrist.     

Beyond brand names of psychotherapy: Identifying empirically supported change processes

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

A crossover study of focused cognitive therapy for panic disorder.

OBJECTIVE: This study sought to determine the short- and long-term effects of focused cognitive therapy for panic disorder. METHOD: Thirty-three psychiatric outpatients with the DSM-III diagnosis of panic disorder were randomly assigned to either 12 weeks of individual, focused cognitive therapy or 8 weeks of brief supportive psychotherapy based on principles of client-centered therapy. The patients who received supportive psychotherapy were subsequently given the opportunity to cross over to cognitive therapy for 12 weeks. Patients were rated for panic and depression before therapy, after 4 and 8 weeks of therapy, and at 6-month and 1-year follow-up. RESULTS: Clinician ratings and self-ratings of panic frequency and intensity indicated that the focused cognitive therapy group achieved significantly greater reductions in panic symptoms and general anxiety after 8 weeks of treatment than did the group that received brief supportive psychotherapy. At 8 weeks, 71% of the cognitive therapy group were panic free, compared to 25% of the psychotherapy group. Moreover, 94% of the psychotherapy patients elected to cross over to 12 weeks of cognitive therapy. At 1-year follow-up, 87% of the group that received cognitive therapy only and 79% of the group that crossed over into cognitive therapy remained free of panic attacks. CONCLUSIONS: Focused cognitive therapy offers a promising nonpharmacological alternative for the treatment of panic disorder.     

Emotion-focused psychotherapy for patients with panic disorder.

OBJECTIVE: Recent studies have suggested that most patients treated for panic disorder receive forms of psychotherapy other than cognitive behavior therapy, even though there is little information about the efficacy of such treatments or how they compare to proven active treatments. The authors compared one of these other forms, emotion-focused psychotherapy (given to 30 patients with panic disorder), to results obtained with recommended standard treatment (either cognitive behavior therapy [N=36] or imipramine [N=22]). The authors also compared emotion-focused psychotherapy to results obtained in subjects given pill placebo (N=24). METHOD: Subjects met DSM-IV criteria for panic disorder with no more than mild agoraphobia. Treatment consisted of approximately 3 months of weekly visits followed by 6 monthly maintenance visits. Assessments were conducted after each treatment phase and at a follow-up visit after 6 months of no treatment. RESULTS: Emotion-focused psychotherapy was less effective for symptoms of panic disorder than treatment with either cognitive behavior therapy or imipramine; results obtained with emotion-focused psychotherapy after the acute and maintenance phases were similar to those seen with placebo. Treatment expectations were not different among the different groups. Patients receiving emotion-focused psychotherapy had the highest completion rate. CONCLUSIONS: The results suggest that emotion-focused psychotherapy (a supportive form of psychotherapy) has low efficacy for the treatment of panic disorder. However, emotion-focused psychotherapy may be superior to medical management in helping patients stay in treatment.     

心理动力性心理治疗合并药物治疗对焦虑障碍患者防御方式的影响

目的 了解心理动力性心理治疗合并药物治疗对焦虑障碍患者防御方式的影响.方法 本研究26例符合DSM- IV诊断标准的焦虑障碍患者进行6个月的心理动力性心理治疗合并药物治疗,对患者进行治疗前后防御方式问卷(DSQ)、汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)评定及比较.结果 6个月重测时HAMD(4.79±5.86)和HAMA(5.42±7.204)均较治疗前(17.88±11.01)、(19.67±8.35)明显降低(t1=6.143,t2=6.989,P＜0.000).6个月后不成熟防御方式的评分下降显著(t=2.17,P=0.04);成熟型防御机制的评分增高显著(t=-4.84,P＜0.000);中间型防御机制评分下降显著(t=2.24,P=0.035).HAMA减分率与不成熟因子分下降率呈正相关(r=0.426,P=0.038).结论 心理动力性心理治疗合并药物治疗对焦虑障碍患者的焦虑和抑郁症状均有改善,并在改变症状的同时减少了不成熟防御机制的使用.心理动力性心理治疗合并药物治疗较单纯药物治疗更有助于焦虑症患者康复.     

What patient characteristics make therapists recommend psychodynamic psychotherapy or other treatment forms?

In order to study factors that psychodynamic therapists considered to be important for recommendation of treatment, psychiatric diagnoses (DSM-III-R Axes I and II and the GAF) as well as character traits assessed by the Karolinska Psychodynamic Profile (KAPP) were retrospectively assessed in interview case-notes of patients applying for psychodynamic psychotherapy. Recommendation of psychotherapy was predicted by the absence of a personality disorder and high GAF scores, but not by the presence of a psychiatric syndrome. The KAPP differentiated between patients with and without disorders on Axis II, but not on Axis I. Patients who were recommended psychodynamic psychotherapy were healthier on all central KAPP variables compared to those who were recommended other treatments, and they were also characterized by predominantly neurotic personality organization, with inhibition as the most prominent defence.     

Axis I and II comorbidity in agoraphobia: prediction of psychotherapy outcome in a clinical setting

The impact of concurrent Axis I and Axis II disorder diagnoses on the efficacy of psychotherapy in a clinical setting for panic disorder with agoraphobia was studied in a sample of 51 agoraphobic outpatients. Diagnoses were based on the Structured Clinical Interview for DSM-III-R. The effects of secondary major depression, dysthymia, generalized anxiety disorder, and avoidant personality disorder were examined via multiple regression analyses. Major depression was associated with less improvement on phobic behavior at 6-month follow-up, whereas dysthymia and avoidant personality disorder predicted less reduction in the frequency of panic attacks at posttest and follow-up, respectively. There was little evidence that generalized anxiety was associated with poorer outcome in this sample. Limitations to the internal validity of the study include uncontrolled use of medication and naturalistic treatment during the follow-up period.     

Psychodynamic psychotherapy of ADHD: A review of the literature

Contributions of psychodynamic psychotherapy to the treatment of children with attention deficit hyperactivity disorder (ADHD) have been sparse. However, mixed results of other interventions, including behavior therapy and medication, call for a systematic examination of psychodynamic contributions to treatment of ADHD children. A systematic review of the literature on psychodynamic psychotherapy with ADHD children yielded a combination of 23 case studies, research reports, and theoretical writings. Questions relevant to the practice of psychodynamic psychotherapy were the focus and included a review of psychodynamic diagnosis of ADHD, theoretical orientations of psychodynamic psychotherapy, identification of core treatment issues, clinical examples, and theoretical perspectives on therapeutic change as well as practice techniques. A review of 231 abstracts resulted from key word searches including ADHD, Psychotherapy, Psychodynamic, and Psychoanalytic. Once inclusion criteria were met, the information from the literature was organized according to categories reflecting the review's focus. Findings of the review are provided to guide psychodynamic psychotherapists in their treatment of ADHD children. Recommendations for future individual and group studies are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Contributions of psychodynamic approaches to treatment of PTSD and trauma: a review of the empirical treatment and psychopathology literature

Reviews of currently empirically supported treatments for post-traumatic stress disorder (PTSD) show that despite their efficacy for many patients, these treatments have high nonresponse and dropout rates. This article develops arguments for the value of psychodynamic approaches for PTSD, based on a review of the empirical psychopathology and treatment literature. Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments. They may be particularly helpful when treating complex PTSD. Empirical and clinical evidence suggests that psychodynamic approaches may result in improved self-esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. Additionally, psychodynamic psychotherapy tends to result in continued improvement after treatment ends. Additional empirical studies of psychodynamic psychotherapy for PTSD are needed, including randomized controlled outcome studies.     

Unrecognized Antagonisms Complicating Business Enterprise

Abstract

Reviews of currently empirically supported treatments for post-traumatic stress disorder (PTSD) show that despite their efficacy for many patients, these treatments have high nonresponse and dropout rates. This article develops arguments for the value of psychodynamic approaches for PTSD, based on a review of the empirical psychopathology and treatment literature. Psychodynamic approaches may help address crucial areas in the clinical presentation of PTSD and the sequelae of trauma that are not targeted by currently empirically supported treatments. They may be particularly helpful when treating complex PTSD. Empirical and clinical evidence suggests that psychodynamic approaches may result in improved self–esteem, increased ability to resolve reactions to trauma through improved reflective functioning, increased reliance on mature defenses with concomitant decreased reliance on immature defenses, the internalization of more secure working models of relationships, and improved social functioning. Additionally, psychodynamic psychotherapy tends to result in continued improvement after treatment ends. Additional empirical studies of psychodynamic psychotherapy for PTSD are needed, including randomized controlled outcome studies.     

Manualized supportive-expressive psychotherapy versus nonmanualized community-delivered psychodynamic therapy for patients with personality disorders: bridging efficacy and effectiveness

OBJECTIVE: Time-limited manualized dynamic psychotherapy was compared with community-delivered psychodynamic therapy for outpatients with personality disorders. METHOD: In a stratified randomized clinical trial, 156 patients with any personality disorder diagnosis were randomly assigned either to 40 sessions of supportive-expressive psychotherapy (N=80) or to community-delivered psychodynamic therapy (N=76). Assessments were made at intake and 1 and 2 years after intake. Patients were recruited consecutively from two community mental health centers (CMHCs), assessed with the Structural Clinical Interview for DSM-IV Axis II Personality Disorders, and included if they had a diagnosis of any DSM-IV personality disorder. The outcome measures included the presence of a personality disorder diagnosis, personality disorder severity index, level of psychiatric symptoms (SCL-90), Global Assessment of Functioning Scale score, and number of therapy sessions. General mixed-model analysis of variance was used to assess group and time effects. RESULTS: In both treatment conditions, the global level of functioning improved while there were decreases in the prevalence of patients fulfilling criteria for a personality disorder diagnosis, personality disorder severity, and psychiatric symptoms. There was no difference in effect between treatments. During the follow-up period, patients who received supportive-expressive psychotherapy made significantly fewer visits to the CMHCs than the patients who received community-delivered psychodynamic therapy. CONCLUSIONS: Manualized supportive-expressive psychotherapy was as effective as nonmanualized community-delivered psychodynamic therapy conducted by experienced dynamic clinicians.     

Headlock: psychotherapy of a patient with multiple neurological and psychiatric problems.

Psychodynamic psychiatrists seldom engage in psychotherapy with brain-injured patients because psychodynamic treatment typically depends on the patient's highly developed verbal skills, reflectiveness, tolerance of frustration, and capacity for abstract thinking and generalization--characteristics impaired by brain injury. The author describes the difficult but successful extended treatment of a young adult patient with preexisting attention-deficit hyperactivity disorder and personality disorders who had also abused alcohol and drugs and had suffered severe brain trauma. Treatment was characterized by a lengthy developmental process, the success of which depended on several factors, particularly the maintenance of the therapeutic alliance.     

Outcomes in a referral cohort of patients with anxiety disorders

This study describes 6- and 12-month outcomes in a referral cohort with anxiety disorders and identifies treatment and prognostic factors related to these outcomes. Patients were recruited at three general hospital clinics, two psychologist-run clinics, and one psychiatric hospital clinic. Outcomes included severity of symptoms, physical and mental health status, and subjective global change in problem severity. Of 254 patients eligible for follow-up, 165 (65.0%) completed a follow-up questionnaire. Methods of treatment included consultation with return to the primary care physician (38.2%); or continued treatment at the clinic, with medications (16.4%), psychotherapy (22.4%), or both (23.0%). Both severity of symptoms and mental health status improved but remained abnormal at follow-up. In multiple logistic regression, subjective global improvement was related to a diagnosis of panic disorder only, treatment with psychotherapy, and type of referral. Change over time in symptom severity was related to clinic type, and change over time in mental health was related to clinic type and duration of previous treatment.     

The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis

OBJECTIVE: The authors conducted a meta-analysis to address the effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders. METHOD: Studies of psychodynamic therapy and cognitive behavior therapy that were published between 1974 and 2001 were collected. Only studies that 1) used standardized methods to diagnose personality disorders, 2) applied reliable and valid instruments for the assessment of outcome, and 3) reported data that allowed calculation of within-group effect sizes or assessment of personality disorder recovery rates were included. Fourteen studies of psychodynamic therapy and 11 studies of cognitive behavior therapy were included. RESULTS: Psychodynamic therapy yielded a large overall effect size (1.46), with effect sizes of 1.08 found for self-report measures and 1.79 for observer-rated measures. For cognitive behavior therapy, the corresponding values were 1.00, 1.20, and 0.87. For more specific measures of personality disorder pathology, a large overall effect size (1.56) was seen for psychodynamic therapy. Two cognitive behavior therapy studies reported significant effects for more specific measures of personality disorder pathology. For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality disorders. CONCLUSIONS: There is evidence that both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders. Since the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies are necessary that examine specific forms of psychotherapy for specific types of personality disorders and that use measures of core psychopathology. Both longer treatments and follow-up studies should be included.     

Therapeutic interventions related to outcome in psychodynamic psychotherapy for anxiety disorder patients

This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed.     

Nonfearful panic disorder in neurology patients validated by lactate challenge

OBJECTIVE: Nonfearful panic disorder meets the DSM-III-R criteria for panic disorder but is not associated with subjective fear and anxiety. The authors determined its prevalence in a group of neurology patients and assessed its diagnostic validity as a panic disorder subtype by evaluating the response of the patients with nonfearful panic disorder to sodium lactate and antipanic pharmacotherapy. METHOD: The subjects were all neurology patients referred over 1 year to a university hospital's psychiatric consultation service because of negative medical workups for their symptoms (N = 48). Patients who met the DSM-III-R criteria for panic disorder but did not report subjective anxiety or fear during panic episodes were diagnosed as having nonfearful panic disorder. Afterward, each of those patients received a sodium lactate infusion and, 5 hours later, a sodium chloride infusion. They were then treated with antipanic medication and followed for at least 6 months. RESULTS: Of the 48 neurology patients referred for psychiatric evaluation, 11 (23%) met the criteria for panic disorder, and all 11 met the criteria for nonfearful panic disorder. All 11 responded positively to lactate but not to placebo, and they each experienced an at least 75% reduction in symptoms during the 6-month follow-up period. Detailed case reports of three of these patients are presented. CONCLUSIONS: These findings support the construct and predictive diagnostic validity of nonfearful panic disorder as a subtype of panic disorder and suggest that a lack of attention to this group leads to both the underestimation of the prevalence of panic disorder and to the withholding of potentially successful treatments for this group.     

Testing psychodynamic psychotherapy skills among psychiatric residents: the psychodynamic psychotherapy competency test

OBJECTIVE: Training in psychodynamic psychotherapy remains a core requirement of psychiatric residency training programs, yet no standard measures of competency exist to document residents' knowledge and skills in this area. To address this issue, the authors developed a written test of applied knowledge of psychodynamic psychotherapy technique and theory, the Psychodynamic Psychotherapy Competency Test. Their goal in this article was to evaluate the validity of this test. METHOD: The test was given to a group of 36 psychoanalytic experts and 206 residents in their second, third, and fourth psychiatric postgraduate years from 10 programs located in different parts of the United States. Program directors provided information on the number of hours of psychodynamic didactic teaching, supervision, and resident-conducted psychodynamic psychotherapy and rated the psychodynamic psychotherapy skills of residents in their fourth postgraduate year on the basis of cumulative supervisor reports. RESULTS: There were significant differences in test performance between residents and faculty experts and between residents in their second and fourth postgraduate years: more advanced residents and experts had progressively better scores. The mean scores of fourth-year residents in different programs differed significantly, but the scores of second-year residents did not. Higher test scores were positively associated with both number of hours of resident-conducted psychotherapy and number of hours of supervision. Among fourth-year residents, test scores correlated significantly with program director evaluations. CONCLUSIONS: This initial study supports the validity of the Psychodynamic Psychotherapy Competency Test as well as the feasibility of testing psychotherapy skills in a standardized fashion.     

Foreløbige erfaringer med lobotomia frontalis

Objective: To study the correlation of personality traits measured by the Temperament and Character Inventory (TCI) with the prognosis of major depressive disorder in patients treated with either fluoxetine or short-term psychodynamic psychotherapy in a randomized comparative study. Method: 35 patients with DSM IV-defined major depressive disorder of mild or moderate severity were randomized to receive either short-term psychodynamic psychotherapy or fluoxetine treatment for 16 weeks. Prior to beginning of the therapy, patients were assessed with TCI. The Hamilton Depression Rating Scale (HDRS) was used as the outcome measure completed at the baseline and follow-up at 4 months. Results: In the combined group (n=35), Harm Avoidance was associated with the severity of the depression measured by the HDRS at the baseline (P=0.01) and baseline Self-Directedness with the HDRS at 4 months follow-up (P=0.03). In the fluoxetine treatment group, Reward Dependence (P=0.03), Self-Directedness (P=0.01) and Cooperativeness (P=0.02) at the baseline associated with HDRS at 4 months follow-up. No statistically significant associations between personality traits and depression scores at the follow-up were found in the patients treated with psychotherapy. Conclusion: In this whole cohort of depressive patients, baseline high Self-Directedness predicted higher depression scores after 4 months of treatment. In the fluoxetine treatment group, subjects with high baseline Reward Dependence, Self-Directedness or Cooperativeness were likely more severely depressed at the 4 months follow-up. We suggest that associations between personality traits and remaining depressive symptoms after 4 months treatment with fluoxetine could be caused by the potential differences in the placebo effect.