Overcoming the narcissism of small differences

Anxiety disorders represent a significant public health concern due to their prevalence, associated impairment and economic impact (Gustavsson et al., 2011; Wittchen et al., 2011). Various empirically supported methods of psychodynamic therapy for the treatment of anxiety disorders are available (a review was recently given by Leichsenring, Klein, and Salzer, 2014).

In clinical practice, you may come across a patient diagnosed with both a social anxiety disorder and a comorbid panic disorder. So what treatment approach to apply? Malan’s (1979) brief psychodynamic therapy supported by Knijnik et al. (2004) and Bögels et al. (2014)? Or the concept by Leichsenring, Beutel, and Leibing (2007) based on Luborsky´s (1984) supportive expressive therapy? Or should we apply the concept of panic-focused psychodynamic therapy by Busch et al. (2012) which has proven to be efficacious in panic disorder (Milrod et al., 2007) and has been extended to other anxiety disorders? In the training of psychotherapists, we are confronted with a similar problem.

Is it necessary that candidates learn to apply all empirically supported treatment concepts for the different mental disorders?

Moving towards transdiagnostic and modular treatments

To address these problems, psychotherapy research is moving its focus from single-disorder approaches towards transdiagnostic and modular treatments (e.g. Barlow, Allen & Choate, 2004; McHugh, Murray & Barlow, 2009). The rationale for transdiagnostic treatments focuses on similarities among disorders, particularly in a similar class of diagnoses (e.g., anxiety disorders) including high rates of comorbidity (e.g., Kessler et al., 2005) and improvements in comorbid conditions when treating a principal disorder (e.g. Barlow, Allen & Choate, 2004; McHugh, Murray & Barlow, 2009; Norton & Phillip, 2008).

Empirical support for transdiagnostic treatment

Psychodynamic therapy has proven to be efficacious in anxiety disorders (Keefe et al., 2014; Leichsenring, Klein & Salzer, 2014). However, a unified and transdiagnostic protocol that integrates principles of empirically supported treatments has not existed so far.

The available evidence for psychodynamic therapy in specific mental disorders comes from randomized controlled trials (RCTs) that used different treatment concepts (Leichsenring, Klein & Salzer, 2014). This implies that the evidence for psychodynamic therapy is “scattered” between the different forms of psychodynamic therapy, not only for anxiety disorders, but for other mental disorders as well (Leichsenring, Klein & Salzer, 2014).

Interestingly, it was for this very reason that psychodynamic therapy was judged as only “possibly efficacious” (Chambless and Hollon, 1998) –  to be judged as “efficacious” at least two RCTs are required in which the same treatment is effectively applied to the same mental disorder (Chambless & Hollon, 1998).

Overlapping characteristics of psychodynamic therapies

Psychodynamic therapy shows several characteristics that facilitate the development of a unified psychodynamic protocol: 

(1) Psychodynamic psychotherapy is transdiagnostic in origin 

Psychodynamic psychotherapy is traditionally not tailored to single mental disorders or specific symptoms. It focuses on core underlying processes of disorders; that is, on unresolved conflicts or structural deficits defined as impairments of ego-functions (e.g., affect regulation, mentalization, internalized object relations or insecure attachment). Thus, psychodynamic therapy is transdiagnostic in origin.

(2) Psychodynamic treatment manuals have a modular format

Treatment manuals for psychodynamic therapy typically have a modular format allowing for a flexible use. This is especially true for the available manual-guided psychodynamic treatments for anxiety disorders (e.g., Busch et al., 2012; P. Crits-Christoph et al., 1995; Leichsenring, Beutel & Leibing, 2007).  By the modular format, both the course of treatment and individual differences between patients (e.g., patient motivation, severity of pathology) can be taken into account. The modular format also allows the “dose” of each treatment element to be adapted to each individual patient’s needs.

(3) Manual-guided methods of psychodynamic therapy for anxiety disorders have core treatment principles in common

The available evidence-based forms of psychodynamic therapy for anxiety disorders have several core principles in common that outweigh the differences between the treatments. This applies to the treatment of panic disorder with and without agoraphobia (Busch et al., 2012; Wiborg & Dahl, 1996), generalized anxiety disorder (P Crits-Christoph et al., 1995)and social anxiety disorder (Bögels et al., 2014; Knijnik et al., 2004; Leichsenring, Beutel & Leibing, 2007).

Developing a unified protocol for the psychodynamic treatment of anxiety disorders

We are here proposing a unified psychodynamic protocol for anxiety disorders (UPP-ANXIETY) that integrates the treatment principles of those methods of psychodynamic therapy that have proven to be efficacious in anxiety disorders.

 The term “unified” refers to several aspects that are integrated:

(a) different treatment principles used by different empirically supported methods of psychodynamic therapy in

(b) various types of anxiety disorders were integrated within a unified protocol for

(c) a diagnostic class of anxiety disorders, thus

(d) also contributing  to  “unifying” the evidence of psychodynamic therapy and enhancing the evidence-based status of psychodynamic therapy .

In addition, this protocol is transdiagnostic implying that is it is applicable to various forms of anxiety disorders and related disorders (generalized anxiety disorder, social phobia, panic disorders, avoidant personality disorder). Based on supportive-expressive therapy (Luborsky, 1984), the UPP-ANXIETY represents an integrated form of psychodynamic therapy that allows for a flexible use of empirically supported treatment principles.

The 9 treatment principles (modules) of UPP-ANXIETY:

  1. socializing the patient for psychotherapy
  2. motivating and setting treatment goals
  3. establishing a secure helping alliance
  4. identifying the core conflict underlying anxiety
  5. focusing on the warded-off wish/affect
  6. modifying underlying internalized object relations
  7. changing underlying defences and avoidance
  8. modifying underlying response of self;
  9. termination and relapse prevention.

Summary and benefits

The benefits of a unified and transdiagnostic protocol for the psychodynamic treatment of anxiety disorders include:

  • Integration of the most effective treatment principles of empirically supported psychodynamic treatments for anxiety disorders which can be expected to further improve the efficacy of psychodynamic therapy
  • Enhancement of the evidence-based status of psychodynamic therapy by aggregating the evidence
  • Facilitation of both training in psychodynamic therapy and transfer of research to clinical practice, thereby significantly impacting the health care system

References

Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a Unified Treatment for Emotional Disorders. Behavior Therapy, 35, 205-230.

Bögels, S. M., Wijts, P., Oort, F. J., & Sallaerts, S. J. (2014). Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorders. Depression and Anxiety, doi 10.1002/da.22246. doi: 10.1002/da.22246

 Busch, F. N., Singer, M. B., Milrod, B. L., & Aronson, A. C. (2012). Manual of panic focused psychodynamic psychotherapy – extended range. New York: Taylor & Francis.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. J Consult Clin Psychol, 66, 7-18.

Crits-Christoph, P., Crits-Christoph, K., Wolfpalacio, D., Fichter, M., & Rudick, D. (1995). Supportive-expressive dynamic psychotherapy for generalized anxiety disorder. In J. P. Barber & P. Crits-Christoph (Eds.), Dynamic therapies for psychiatric disorders: Axis I (pp. 43-83). New York: Basic Books.

Crits-Christoph, P., Wolf-Palacio, D., Ficher, M., & Rudick, D. (1995). Brief supportive-expressive psychodynamic therapy for generalized anxiety disorder. In J. Barber & P. Crits-Christoph (Eds.), Dynamic therapies for psychiatric disorders (Axis I). New York: Basic Books.

Gustavsson, A., Svensson, M., Jacobi, F., Allgulander, C., Alonso, J., Beghi, E., et al. (2011). Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol, 21(10), 718-779.

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

Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627.

Knijnik, D. Z., Kapczinski, F., Chachamovich, E., Margis, R., & Eizirik, C. L. (2004). Psychodynamic group treatment for generalized social phobia. Revista Brasileira de Psiquiatria, 26, 77-781.

Leichsenring, F., Beutel, M., & Leibing, E. (2007). Psychodynamic psychotherapy for social phobia: a treatment manual based on supportive-expressive therapy. Bulletin of the Menninger Clinic, 71, 56-83.

Leichsenring, F., Klein, S., & Salzer, S. (2014). The efficacy of psychodynamic psychotherapy in specific mental disorders – a 2013 update of empirical evidence. Contemporary Psychoanalysis, 50, 89-130.

Luborsky, L. (1984). Principles of psychoanalytic psychotherapy. Manual for supportive-expressive treatment. New York: Basic Books.

Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. London: Butterworth.

McHugh, R. K., Murray, H. W., & Barlow, D. H. (2009). Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behaviour Research and Therapy, 47, 946-953.

Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., et al. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164(2), 265-272.

Norton, P. J., & Phillip, L. M. (2008). Transdiagnostic approaches to the treatment of anxiety disorders: A quantitative review. Psychotherapy Theory, Research, Practice, Training, 45, 214-226.

Wiborg, I. M., & Dahl, A. A. (1996). Does brief dynamic psychotherapy reduce the relapse rate of panic disorder? Archives of General Psychiatry, 53, 689-694.

Wittchen, H. U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jonsson, B., et al. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. [Research Support, Non-U.S. Gov’t Review]. Eur Neuropsychopharmacol, 21(9), 655-679. doi: 10.1016/j.euroneuro.2011.07.018