1) Significance:
Panic disorder is a serious public health problem, associated with high rates of utilization of medical and psychiatric services, poor overall health, and poor quality of life. Patients with panic disorder have the highest odds ratio of utilizing medical and psychiatric emergency room services, and having medical and psychiatric hospitalizations in comparison with patients with any other psychiatric diagnosis, or patients with no psychiatric diagnosis. Patients with panic disorder have the highest odds-ratio of visiting general medical practitioners six or more times within six months compared with patients with any other psychiatric diagnosis, or in comparison to patients with no psychiatric diagnosis. Patients with PD report poor physical health, poor emotional health, higher incidence of alcohol and drug abuse than "normals," and a high prevalence of attempted suicide. Both cognitive-behavioral treatment and psychopharmacologic treatments have yielded high initial success rates in the treatment of panic patients. Nonetheless, these patients frequently require continued treatment and regularly do not experience full remission. Long-term outcome of short term treatment interventions show high rates of relapse and continued impaired global function with persistent, ongoing anxiety symptoms in many patients following treatments which initially brought about symptomatic relief. Some patients are unable to tolerate or do not respond to these treatments. Studied treatments have traditionally focused on panic disorder and agoraphobic symptoms, and have been less concerned with related psychological and psychosocial difficulties commonly found in panic patients. Because panic disorder is prevalent among women of childbearing age, it is imperative to explore potentially effective nonpharmacological alternatives. In one influential study, effective treatment of panic disorder has been shown to offset costs of medical care by as much as 94%, making it imperative to identify treatments that will minimize relapse.


In 1991, Milrod and Shear found 35 cases in the literature with DSM-III-R panic disorder who had been successfully treated with psychodynamic psychotherapy or psychoanalysis alone. Since then, other successful psychodynamic treatments for patients with panic disorder have been reported. These reports suggest that psychodynamic treatment can bring relief, often as rapidly as psychopharmacologic or cognitive-behavioral interventions. Nonetheless, the number of patients who have been treated with psychodynamic psychotherapy who have had careful serial assessment evaluations of their outcome and/or manualized treatment is limited. Most empirical psychotherapy studies have examined cognitive and behavioral therapy, even though most clinical psychotherapy practiced in this country is psychodynamic. It is crucial to the field of psychodynamic psychiatry to test its efficacy. To date, no prospective studies exist documenting the efficacy of psychodynamic psychotherapy alone for the treatment of panic disorder, although this group is currently running the first such study. As more long-term outcome data become available about effects of treatment strategies that have been heretofore studied, the more it is evident that we have yet to find lasting treatment solutions for panic disorder. In the most recent large-scale, carefully-conducted outcome study of patients with panic disorder, the response rate for panic patients treated with imiprimine was 45.8%, while CBT achieved a 48.7% response. Combination treatment with imiprimine and CBT fared somewhat better (60.3%), although the differences in rate of response to combined treatment in comparison with either active treatment alone did not reach statistical significance, either in acute or follow-up evaluations. While these figures are impressive, they leave room for improvement. Psychodynamic psychotherapy may be able to bring about wider-ranging, more lasting relief.

2) Results: Our studies have provided free, high-quality psychotherapy for patients with panic disorder. Most of our study patients would not otherwise have been able to afford any treatment, and certainly not psychotherapy, as they are largely working and lower-middle class, without psychiatric health care coverage. This study has been overwhelmed with requests for treatment since the terrorist attacks on New York City, on September 11, 2001. 1)Recruitment for the open trial of Panic-Focused Psychodynamic Psychotherapy (PFPP) was completed in July,1999. Final data have been analyzed.

Twenty-one subjects entered this open treatment trial. Four subjects dropped out during the course of treatment. The number of dropouts were too few to meaningfully compare with completers on demographic variables, nevertheless all baseline versus 16 week comparisons include 21 subjects using last-observation carried forward.

Sixty-six percent of study entrants were female; 76% were white, 19% were black, 4% were Asian. Forty-three percent were married, 43% single, 4% each were cohabiting, separated, and divorced. Ninety-five percent were employed. Thirty-three percent had children. The mean current age was 32 years (sd 8 yrs). Seventy-six percent had primary DSM-IV panic disorder with agoraphobia; 24% had primary DSM-IV panic without agoraphobia. Average severity of panic was 5.7 on a scale of 1-8 on the ADIS. Eighty-one percent of this sample had at least one active comorbid DSM-IV Axis I diagnosis of significant clinical severity: Twenty-four percent had comorbid major depression, 24% had dysthymia. Mean length of the current panic episode was 3 years (sd 1.7 years). Thirty-eight percent of subjects underwent medication taper off ineffective anti-panic regimens prior to study entry.

The data indicate substantial reduction not only in panic attacks and preoccupation with panic attacks per se, but also in a wide range of anxious cognitions that frequently affect patients with panic disorder: concerns about their bodies, fears, and general arousability and high levels of resting anxiety. Impairments in quality of life, a serious problem for these patients, improved as well. It is very heartening that there was no decline in function across any measured symptomatic area at six months' follow-up, after a six-month no treatment period.
2)This project has been funded by the National Institute of Mental Health, K23 series, in addition to the New York Community Trust to conduct an efficacy study: a small randomized controlled trial, comparing PFPP applied relaxation training (ART) and to determine the effects of these treatments on panic frequency and overall panic disorder symptomatology as well as specific symptom measures and quality of life. ART has been chosen for this purpose because it is felt to be a less active treatment for panic based on randomized clinical trials showing that it was less effective than CBT (response rates of 13-22.2% have been reported for applied relaxation training giving it a similar response profile to pill-placebo), while it also controls for therapist contact and has credibility as an anti-panic treatment. A no treatment or delayed treatment cell was decided against because of its questionable ethical status for patients in crisis, such as panic patients.

This study is beginning its fifth year, and 44 patients have thus far been randomized and treated with one of these two forms of treatment. Patients will be followed for 12 months post-treatment termination in this study. We have done a limited interim data analysis, although the study continues to enter new patients.
3)Pilot Study in Adolescents: The P.I. and one co-author of the PFPP manual, Theodore Shapiro, M.D., are child and adolescent psychiatrists, and always planned to extend this research to include adolescents with panic disorder. This is a population of patients in dire need of effective nonpharmacological anti-panic treatments. During our adult studies, we noticed that core issues of adolescent development frequently emerge during PFPP treatments in adults. One approach to the problem of panic disorder treatment gains not being maintained in the absence of continued treatment is to treat patients earlier, in the hopes of achieving more permanent remissions. We have now completed a manual of PFPP for adolescents (PFPP-A), and have designed adolescent adherence rating scales for PFPP-A that have been found to have the excellent reliability with the adolescent patients who have been included heretofore in our adult studies.