What is Panic-Focused Psychodynamic Psychotherapy?

Panic-focused psychodynamic psychotherapy (PFPP) is a specialized form of psychotherapy developed specifically for the treatment of panic disorder. It combines elements of psychodynamic therapy, which focuses on unconscious psychological processes, with interventions tailored to address the underlying emotional conflicts and developmental deficits thought to contribute to panic symptoms.

PFPP is a time-limited treatment, typically consisting of 24 sessions over 12 weeks. It aims to help patients better understand and work through the underlying emotional and psychological issues driving their panic attacks, leading to a reduction in symptoms and improved overall functioning.

Is Panic-Focused Psychodynamic Psychotherapy Evidence-Based?

While PFPP is a relatively new treatment approach compared to well-established therapies like cognitive-behavioral therapy (CBT), growing evidence supports its efficacy for panic disorder. Several studies, including randomized controlled trials, have found PFPP to be effective in reducing panic symptoms, with benefits maintained over follow-up periods ranging from six months to several years.

However, as with many psychodynamic therapies, conducting rigorous empirical research on PFPP can be challenging due to the individualized and subjective nature of the treatment. More research is needed to establish PFPP as a definitively evidence-based treatment for panic disorder. Nonetheless, the existing evidence is promising and supports PFPP as a viable treatment option.

What are the Core Assumptions and Tenets of PFPP?

The core premise of PFPP is that panic attacks and panic disorder result from underlying emotional conflicts and developmental deficits that have not been adequately resolved. These may include fears of loss, abandonment, anger, and guilt, often stemming from early attachment relationships and experiences.

Key assumptions of PFPP include:

1. Panic symptoms have meaning and are linked to underlying emotional conflicts
2. Developmental experiences shape vulnerability to panic and influence symptom presentation
3. Resolving emotional conflicts and processing developmental traumas can alleviate panic symptoms
4. The therapeutic relationship provides a corrective emotional experience that facilitates change

PFPP also emphasizes the role of transference, or the patient’s emotional reactions to the therapist based on past relationships. By exploring and working through these reactions in the therapy relationship, patients can gain insight and find healthier ways of relating to others and regulating their emotions.

Who Developed Panic-Focused Psychodynamic Psychotherapy?

PFPP was developed by Barbara Milrod, M.D., a psychiatrist and psychoanalyst, and her colleagues at Weill Cornell Medical College in the 1990s. Dr. Milrod’s clinical observations and research on panic disorder led her to believe that existing treatments, while helpful for some patients, did not adequately address the deeper psychological factors contributing to panic symptoms.

Drawing on her psychoanalytic training and influenced by attachment theory and object relations, Dr. Milrod developed a treatment model that integrated psychodynamic principles with a focus on the specific developmental and emotional issues underlying panic disorder. She collaborated with colleagues including Fredric Busch, M.D., and Theodore Shapiro, M.D., to refine and manualize the treatment.

How was PFPP Developed and Disseminated?

Key events in the development and dissemination of PFPP include:

• 1997: First published description of PFPP in the Journal of Psychotherapy Practice and Research
• 2001: Publication of “Psychodynamic Therapy for Panic Disorder: A Treatment Manual”
• 2007: First randomized controlled trial of PFPP published, demonstrating efficacy
• 2012: American Psychiatric Association releases PFPP treatment manual
• Ongoing: Workshops, trainings, and supervision to spread PFPP among clinicians

The development of PFPP was influenced by the recognition in the 1990s that panic disorder had identifiable biological underpinnings. This led to a surge of interest in panic from a medical model and the development of effective medication treatments and CBT protocols. However, Dr. Milrod and her colleagues believed that a psychodynamic approach could complement these treatments and provide a psychological understanding of panic that was lacking.

At the same time, psychoanalysis and psychodynamic therapy were facing increasing pressure to demonstrate their scientific validity and efficacy. The effort to manualize PFPP and subject it to empirical testing can be seen as part of a broader movement to place psychodynamic treatments on firmer scientific footing.

Economically, the rise of managed care and limitations on psychotherapy sessions may have also motivated the development of a focused, time-limited psychodynamic treatment like PFPP that could be more easily integrated into the healthcare system.

What Other Therapies is PFPP Similar To?

PFPP shares theoretical overlaps and some techniques with several other therapy models:

1. Psychodynamic Therapy: As a psychodynamic treatment, PFPP shares a focus on unconscious processes, the role of past experiences in shaping current functioning, and the use of the therapy relationship as a vehicle for change.
2. Mentalization-Based Therapy (MBT): Like MBT, PFPP aims to enhance patients’ ability to understand their own mental states and those of others. Mentalization deficits are seen as a common factor underlying many psychological disorders, including panic.
3. Transference-Focused Psychotherapy (TFP): PFPP places a strong emphasis on working with transference reactions, a hallmark of TFP. However, the focus on transference is more structured and specifically linked to panic symptoms in PFPP.
4. Short-Term Psychodynamic Psychotherapy (STPP): As a time-limited treatment, PFPP shares the goal of achieving symptom improvement within a focused treatment period. However, PFPP is distinct in its specific focus on panic disorder.
5. Emotion-Focused Therapy (EFT): PFPP shares with EFT a focus on helping patients access, process, and regulate underlying emotions. Both see emotional avoidance as a key factor maintaining symptoms.

While sharing elements with these other treatments, PFPP is unique in its integration of these elements into a focused treatment package specifically designed for panic disorder.

What are the Key Interventions and Techniques Used in PFPP?

PFPP utilizes a range of psychodynamic interventions and techniques, tailored to the specific needs of panic disorder patients. Key interventions include:

1. Panic-Focused Psychodynamic Exploration: Therapists help patients explore the thoughts, feelings, and memories associated with their panic attacks, with a focus on identifying underlying emotional conflicts and developmental issues.
2. Transference Interpretation: Therapists highlight and explore patients’ emotional reactions to the therapist that may reflect patterns from past relationships. This helps patients gain insight into their relational patterns and find new ways of relating.
3. Defenses and Resistance Analysis: Therapists gently confront patients’ defenses against emotional experience, such as avoidance or intellectualization, while respecting the role these defenses have played in coping with anxiety.
4. Affective Experience and Expression: Therapists help patients to label, differentiate, and express their emotions, particularly those that have been avoided or suppressed due to their link with panic.
5. Developmental Exploration: Therapists explore patients’ early experiences and attachment relationships to identify developmental origins of emotional vulnerabilities and conflicts underlying panic.
6. Dream Analysis: Therapists may use patients’ dreams as a window into their unconscious fears and conflicts related to panic.
7. Termination and Relapse Prevention: In the concluding sessions, therapists focus on helping patients consolidate gains, anticipate future challenges, and plan for maintaining progress after treatment ends.

Throughout treatment, PFPP therapists strive to create a safe, empathic, and non-judgmental therapeutic relationship that allows patients to explore their experiences and try out new ways of being.

What are the Stages and Goals of PFPP Treatment?

PFPP treatment can be conceptualized in three overarching stages:

1. Initial Phase (Sessions 1-8)
   • Establish therapeutic alliance
   • Assess panic symptoms and related impairment
   • Identify underlying emotional conflicts and developmental issues
   • Provide psychoeducation on the PFPP model of panic
2. Middle Phase (Sessions 9-16)
   • Deepen exploration of emotional conflicts and developmental issues
   • Work through transference reactions in the therapy relationship
   • Help patient to experience and express previously avoided emotions
   • Encourage patient to confront feared situations and sensations
3. Termination Phase (Sessions 17-24)
   • Consolidate treatment gains
   • Explore patient’s reactions to ending treatment
   • Develop relapse prevention plan
   • Help patient internalize therapeutic relationship and insights

The overarching goal of PFPP is to help patients achieve a significant reduction in panic symptoms and related impairment. This is achieved through the resolution of underlying emotional conflicts and the development of more adaptive ways of experiencing and regulating emotions.

At a deeper level, PFPP aims to help patients develop a more coherent and positive sense of self, rooted in a fuller range of emotional experience and healthier attachments. By working through developmental deficits and traumas within the therapy relationship, patients can internalize a new model of relating to self and others.

Successful PFPP treatment results in patients who are not only panic-free but have developed the emotional and relational capacities to confront life’s challenges with greater resilience and flexibility.

How Does PFPP Conceptualize Identity and the Self?

PFPP views the self as fundamentally shaped by early emotional experiences and attachment relationships. A cohesive and positive sense of self emerges from having one’s emotional needs consistently met and painful feelings soothed by attuned caregivers.

However, when developmental needs are not adequately met or traumatic experiences are not processed, the self can become fragmented and organized around avoiding painful emotions and memories. In panic disorder, the self becomes defined by a sense of vulnerability and fear of intense emotion, leading to a constricted way of living designed to keep panic at bay.

The goal of PFPP is to help patients develop a more integrated and resilient sense of self, capable of experiencing a full range of emotions without becoming overwhelmed. Through the therapeutic relationship, patients internalize a new experience of having their emotions understood and soothed, leading to a greater capacity for self-reflection and self-regulation.

In PFPP, identity is not seen as a static entity but a fluid process that evolves through relationships and emotional experiences. By exploring their emotional reactions in the therapy relationship and linking them to developmental experiences, patients can rework their sense of identity to include a greater capacity for intimacy, assertiveness, and autonomy.

Ultimately, PFPP aims not just to eliminate panic symptoms but to foster the development of a self that is vital, spontaneous, and able to embrace life’s challenges and opportunities with creativity and authenticity.

What Contexts is PFPP Usually Practiced In?

PFPP was developed as an outpatient treatment and is typically provided in individual psychotherapy sessions in private practice or outpatient mental health clinic settings. Sessions are usually conducted once or twice weekly, with a total treatment duration of 12 weeks.

As a focused and time-limited treatment, PFPP can be appealing to both patients and third-party payers looking for a cost-effective alternative or complement to longer-term psychodynamic therapies or medication management alone.

PFPP can be used as a standalone treatment for panic disorder or in conjunction with medication treatment. It may be particularly indicated for patients who have not responded adequately to first-line treatments like CBT or medication, or who are interested in a psychodynamic approach to understanding and treating their panic.

While originally developed for adult patients, PFPP has also been adapted for use with adolescents experiencing panic attacks. The principles of PFPP have also been applied to other anxiety disorders such as generalized anxiety disorder and social anxiety disorder, although the specific treatment protocols differ.

As awareness of PFPP grows, it is being increasingly integrated into psychodynamic training programs and continuing education workshops for mental health professionals. With its integration of psychodynamic principles and panic-focused interventions, PFPP offers a unique skill set for therapists looking to expand their repertoire of treatments for anxiety disorders.

What Historical and Cultural Forces Influenced the Development of PFPP?

The development of PFPP in the 1990s can be seen as a product of several converging historical and cultural forces:

1. The Rise of Panic Disorder as a Diagnostic Category: Panic disorder was first introduced as a distinct diagnosis in the DSM-III in 1980, reflecting a growing recognition of the specificity and severity of panic symptoms. This diagnostic shift created a need for targeted treatments for panic disorder.
2. The Influence of the Biological Psychiatry Movement: The 1990s saw a surge of interest in the biological underpinnings of mental disorders, driven by advances in neuroscience and psychopharmacology. While this led to a proliferation of medical treatments for panic disorder, it also created a countervailing interest in psychological models that could complement the biological perspective.
3. The Psychotherapy Integration Movement: The 1990s also witnessed a growing interest in integrating different psychotherapy traditions, moving beyond the “school wars” of earlier decades. PFPP can be seen as part of this integrative trend, combining psychodynamic principles with techniques tailored to the specific features of panic disorder.
4. The Managed Care Revolution: The rise of managed health care in the 1990s created pressure for mental health treatments to be time-limited, cost-effective, and empirically validated. The development of PFPP as a 12-week, manualized treatment with a growing evidence base can be seen as a response to these economic pressures.
5. Cultural Attitudes Towards Anxiety: The 1990s saw a growing public awareness of anxiety disorders, driven in part by the success of SSRIs like Prozac. However, there was also a cultural ambivalence towards anxiety, seen as both a medical condition and a reflection of deeper existential and social malaise. PFPP’s focus on the meaning and context of panic symptoms resonated with a cultural hunger for a deeper understanding of anxiety beyond the biological.
6. Postmodern and Constructivist Influences: The 1990s also saw the growth of postmodern and constructivist perspectives in psychotherapy, emphasizing the co-construction of meaning between therapist and patient. PFPP’s emphasis on the therapy relationship as a crucible for change and its openness to multiple interpretations of panic symptoms reflects this philosophical shift.

In many ways, PFPP can be seen as a product of its historical moment, shaped by the unique confluence of scientific, economic, and cultural forces of the late 20th century. At the same time, it represents a creative synthesis of psychodynamic traditions with the specific needs of panic disorder patients, offering a novel approach to a complex clinical problem.

How Has PFPP Influenced the Field of Psychotherapy?

While PFPP is a relatively young treatment model, it has made significant contributions to the field of psychotherapy in several ways:

1. Legitimizing Psychodynamic Approaches to Anxiety Disorders: Historically, psychodynamic treatments were seen as unsuitable for acute anxiety disorders like panic, which were thought to require more directive, symptom-focused interventions. PFPP has helped to challenge this assumption, demonstrating that a psychodynamic approach can be effective for panic disorder when adapted to the specific features of the condition.
2. Integrating Psychodynamic and Cognitive-Behavioral Approaches: PFPP represents a kind of “third wave” approach that integrates elements of psychodynamic and cognitive-behavioral therapies. By focusing on the meaning and context of panic symptoms while also incorporating exposure and relapse prevention strategies, PFPP has helped to bridge the divide between these two major schools of psychotherapy.
3. Advancing the Empirical Validation of Psychodynamic Treatments: As one of the first manualized and empirically tested psychodynamic treatments for panic disorder, PFPP has contributed to the growing evidence base for psychodynamic therapies. This has helped to counter the perception of psychodynamic approaches as unscientific or untestable, paving the way for further research on psychodynamic treatments for a range of mental health conditions.
4. Expanding the Range of Treatment Options for Panic Disorder: By offering a distinct alternative to CBT and medication, PFPP has expanded the range of treatment options available to patients with panic disorder. This is particularly important given that not all patients respond to first-line treatments, and some may prefer a psychodynamic approach that focuses on personal meaning and relational context.
5. Influencing the Training of Psychodynamic Therapists: As awareness of PFPP has grown, it has increasingly been integrated into the training of psychodynamic therapists. Many psychoanalytic and psychodynamic training programs now include PFPP as part of their curriculum, equipping a new generation of therapists with specific skills for treating panic disorder from a psychodynamic perspective.
6. Cross-Pollinating with Other Psychodynamic Models: The principles and techniques of PFPP have also influenced and been influenced by other contemporary psychodynamic models such as mentalization-based treatment (MBT) and transference-focused psychotherapy (TFP). This cross-pollination has contributed to a broader revival of interest in psychodynamic approaches within the mental health field.

While the full impact of PFPP remains to be seen, it has already made significant contributions to the field of psychotherapy by legitimizing psychodynamic approaches to anxiety disorders, integrating psychodynamic and cognitive-behavioral techniques, advancing empirical research on psychodynamic treatments, and expanding the range of treatment options available to patients suffering from panic disorder. As research on PFPP continues and the model is further disseminated, it has the potential to reshape how we understand and treat anxiety disorders from a psychodynamic perspective.

Timeline of PFPP Development and Milestones

• 1980: DSM-III introduces panic disorder as a distinct diagnostic category
• Early 1990s: Barbara Milrod and colleagues at Weill Cornell Medical College begin developing PFPP
• 1997: First published description of PFPP in the Journal of Psychotherapy Practice and Research
• 2000: PFPP treatment manual is completed
• 2001: “Psychodynamic Therapy for Panic Disorder: A Treatment Manual” is published
• 2007: First randomized controlled trial of PFPP published in the American Journal of Psychiatry, demonstrating efficacy
• 2008: PFPP is recognized as a “probably efficacious” treatment for panic disorder by the Society of Clinical Psychology (Division 12 of the American Psychological Association)
• 2012: American Psychiatric Association releases updated PFPP treatment manual
• 2016: Meta-analysis published in Psychoanalytic Psychology supports the efficacy of PFPP for panic disorder
• 2018: PFPP is integrated into the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders, a CBT-based protocol for anxiety and mood disorders
• Ongoing: Workshops, trainings, and supervision continue to spread PFPP among clinicians; research continues on applications of PFPP principles to other anxiety and mood disorders

This timeline illustrates the gradual development and dissemination of PFPP from an innovative clinical idea in the early 1990s to an empirically supported treatment recognized by major professional organizations by the late 2000s. The publication of treatment manuals and the conduct of randomized controlled trials were key milestones in establishing the credibility and replicability of the PFPP model.

At the same time, the timeline also reflects the ongoing evolution of PFPP as it is integrated with other treatment approaches and applied to a broader range of clinical populations. The incorporation of PFPP into the Unified Protocol in 2018 represents an important step towards a more transdiagnostic and integrative approach to emotional disorders.

As PFPP enters its third decade, it continues to evolve and spread through the efforts of a growing network of researchers and clinicians. While much work remains to be done in refining the model and extending its applications, PFPP has already secured a place as a significant innovation in the psychodynamic treatment of anxiety disorders.

Bibliography and Further Reading

Busch, F. N., Milrod, B. L., Singer, M. B., & Aronson, A. C. (2012). Manual of panic focused psychodynamic psychotherapy – eXtended range. Routledge.

Busch, F. N., Milrod, B. L., & Singer, M. B. (1999). Theory and technique in psychodynamic treatment of panic disorder. The Journal of Psychotherapy Practice and Research, 8(3), 234–242.

Keefe, J. R., McCarthy, K. S., Dinger, U., Zilcha-Mano, S., & Barber, J. P. (2014). A meta-analytic review of psychodynamic therapies for anxiety disorders. Clinical Psychology Review, 34(4), 309–323. https://doi.org/10.1016/j.cpr.2014.03.004

Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. American Psychiatric Press.

Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., … Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164(2), 265–272. https://doi.org/10.1176/ajp.2007.164.2.265

Milrod, B., Chambless, D. L., Gallop, R., Busch, F. N., Schwalberg, M., McCarthy, K. S., … Barber, J. P. (2016). Psychotherapies for panic disorder: A tale of two sites. The Journal of Clinical Psychiatry, 77(7), 927–935. https://doi.org/10.4088/JCP.14m09507

Rudden, M., Busch, F. N., Milrod, B., Singer, M., Aronson, A., Roiphe, J., & Shapiro, T. (2003). Panic disorder and depression: A psychodynamic exploration of comorbidity. The International Journal of Psychoanalysis, 84(4), 997–1015. https://doi.org/10.1516/N4A3-UXHF-YWFU-TQHV

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378

Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. Guilford Press.

Wiborg, I. M., & Dahl, A. A. (1996). Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Archives of General Psychiatry, 53(8), 689–694. https://doi.org/10.1001/archpsyc.1996.01830080041008