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The psychodynamic approach to tr...

Posted Oct 22 2008 6:16pm

The psychodynamic approach to treating panic.
Psychoactive drugs and cognitive-behavioral therapy: Those are the two treatments that everyone seems to agree can work against panic. What about traditional psychotherapy, though? "Psychodynamic Treatment of Panic Disorder" is a piece that looks at a psychotherapeutic approach to treating panic. It's full of food for thought; to wit:

The Unconscious
According to psychoanalytic theory, symptoms are based at least in part on unconscious fantasies and affects.24 For example, clinical and research observation suggests that panic patients have particular difficulties with angry feelings and fantasies, such as wishes for revenge.22,23,25 These wishes represent a threat to important attachment figures, thus triggering anxiety. Patients are often unaware of the intensity of these affects and the vengeful fantasies that accompany them. Becoming aware of these aspects of mental life and rendering them less threatening are important components of psychodynamic psychotherapy.

Defense Mechanisms
Fantasies and affects that are experienced as dangerous can be dealt with through the triggering of defenses, that is, mental processes that disguise the fantasies or render them unconscious.26 Clinical and research observations indicate that panic patients employ particular defenses: reaction formation, undoing, and denial.27 Reaction formation and undoing play a particular role for panic patients in that they attempt to convert an angry affect into a more affiliative one, diminishing the threat to an attachment figure. In reaction formation a threatening feeling is replaced by its opposite; negative feelings of panic patients are oftentimes replaced by concern and efforts to help others. In undoing, a negative affect or fantasy is typically taken back in some way. Denial represents a lack of recognition of the presence of a particular feeling or fantasy, such as a patient reporting he was not angry even after someone had done something hurtful to him. It is generally important to bring these defenses to the patient’s attention as they maintain the patient’s avoidance of exploring the frightening feelings and fantasies. For example, a patient who follows the statement “I hate him” by “but I really love him” (an example of undoing), is often trying to avoid the intensity of his angry feelings.

Compromise Formation
A symptom can represent a compromise between a conflicted wish and a defense against that wish.24 Teasing apart the components of this compromise formation can help to understand the meaning of that symptom and the unconscious factors that are triggering it. Thus, panic symptoms can include the wish to be taken care of, a denial of anger through a focus on anxiety or bodily symptoms, and an unconscious expression of anger in the coercive aspect of pressuring others to help.

Self and Object Representations
Particular self and object representations can trigger a susceptibility to certain symptoms. In systematic assessments, panic patients have been found to have views of their parents as having been controlling, temperamental, and critical.28,29 These expectations of the behaviors of others are internalized. In addition, because of their predisposition to fearfulness, panic patients have a view of others as essential to their safety and well-being. Recognizing these perceptions of self and others can help panic patients understand the danger they experience in communicating wishes to be taken care of as well as angry feelings.
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