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A conflict has arisen between the leadership of the American Psychoanalytic Association and APA over APA's recently published practice guideline on panic disorder (Psychiatric News, February 6).
The psychoanalytic association contends that the guideline accords little recognition to psychodynamic psychotherapy as a treatment for panic disorder, a contention strongly disputed by some of the key architects of the new guideline. A careful reading of the guideline shows that psychodynamic therapy is credited with a role in treating panic disorder. But the guideline tends to give credence to treatments, including cognitive-behavioral therapy (CBT) and medication, that have been proven through controlled trials, as opposed to treatments supported mainly by clinical consensus.
The psychoanalytic association voted unanimously to "record its strong objections" to the panic disorder guideline in May. The psychoanalytic association has also written a letter of protest to the American Journal of Psychiatry (AJP), which will appear in an as yet undetermined issue. The journal published the guideline as a supplement to its May issue.
The psychoanalytic association's objections were summed up in a statement provided to Psychiatric News: "The guideline fails to recognize the clinical value of psychodynamic psychotherapy and psychoanalysis in the treatment of severe anxiety disorders including panic symptoms. Although the guideline does suggest their potential usefulness for comorbid conditions, the monosymptomatic approach of the guideline neglects the individual suffering from the symptoms, fails to maintain a biopsychosocial orientation, and skews research findings in favor of narrow and short-term outcomes. The guideline does not address the clinical issues of long-term outcome."
Former APA president John McIntyre, M.D., chairs the APA Steering Committee on Practice Guidelines. McIntyre spoke with Psychiatric News about the controversy.
The panic disorder guideline states in "a number of places" that clinicians have found psychodynamic treatments effective, said McIntyre. It is not true that CBT and medication are the only therapies validated, he added.
"It is true, however, that research with well-controlled studies does support the efficacy of both medication and CBT, and there is not that level of research support for psychoanalytic treatments."
Robert Pyles, M.D., president of the American Psychoanalytic Association, spoke with Psychiatric News about the controversy.
"I think the guideline's merging of CBT and psychodynamic psychotherapy is a big mistake," said Pyles. "I think that most psychodynamic psychotherapists would feel that there is a dramatic difference between the two, a difference that was really not explicated in the guideline."
The guideline relegated psychodynamic psychotherapy to the treatment of comorbid conditions and failed to recommend psychodynamic psychotherapy as one of the "first-line treatments for panic disorder," said Pyles. "Even the inclusion in the treatment section of one sentence stating that 'in selected cases, psychodynamic psychotherapy may be the treatment of choice' would go a very long way toward answering some of our concerns."
The psychoanalytic association "does not agree that this particular guideline reflects a true biopsychosocial viewpoint," Pyles said. "We feel this guideline was constructed very narrowly, both in terms of what the [work group] deemed scientific data and also what they considered to be the nature of the syndrome itself. What we are saying is that panic disorder almost never occurs in isolation. I think what we've got here is a short-term, managed care model. It was our concern that the guideline reflected more economic and political issues than true scientific ones."
The guideline focuses on "very short-term treatment and symptom relief of a very narrowly defined condition," said Pyles, and minimizes "experience-based data."
It is unfortunate for this controversy to occur at a time when he, as president, is trying to rebuild ties between the psychoanalytic association and APA, said Pyles.
"I am really putting a big push on for our members to rejoin APA, and obviously if our people don't feel that our views on psychodynamic therapy are being reflected in the guidelines, it really works against our bringing together the two organizations."
McIntyre disagreed with the views of the psychoanalytic association and Pyles. Like all APA practice guidelines, the set on panic disorder reflects both published research and clinical consensus, McIntyre said. "Every guideline has a very heavy dose of both." APA guidelines "have a very strong commitment to a biopsychosocial approach."
The panic disorder guideline states "very clearly that there is strong research supporting the notion that psychotherapy is effective, that talking with patients, that focusing on verbal interactions, makes a difference, and makes a difference as much as medication," said McIntyre. "That is a very powerful statement in this era of focusing on medication and quick visits, and I think that is being minimized [by the critics] because it does not refer to a specific form of psychotherapy."
Norman Clemens, M.D., is APA's Area 4 trustee and chair of the APA Commission on Psychotherapy by Psychiatrists. During the writing of the panic disorder guideline, said Clemens, he worked to "try and get at least a minimum recognition" of psychodynamic therapy included. The commission "felt that in view of the lack of randomized trials on psychodynamic therapy, we couldn't get as much as we'd like," Clemens explained. But the commission succeeded in "getting it mentioned specifically and given more prominence in comorbid conditions," he added.
Although it is true that the panic disorder guideline does not address psychoanalysis, the commission decided that since "very few people with panic disorder right off the street go right into psychoanalysis," pushing for a specific mention "wasn't a battle worth fighting."
Clemens, who is also a member of the psychoanalytic association, said that despite his sympathy for the views expressed by the psychoanalytic association, he believes that analysts "must come to terms with an environment that increasingly relies on a certain kind of evidence provided by systematic, randomized, controlled trials." Although there is a consensus that psychodynamic therapy works, the challenge is to "increase research on psychoanalysis and psychodynamic therapy that will be given credibility by the larger scientific community," he said.
Sara Charles, M.D., is vice chair of APA's Steering Committee on Practice Guidelines. She noted that the guidelines are designed to be "as evidence based as possible. It is true that the majority of the studies cited in the guideline supporting CBT and medication were time limited."
The problem with psychodynamic psychotherapy is "the evidence isn't there," Charles continued. "One of the useful things about this conflict" is that it is mobilizing the psychoanalytic community to establish the efficacy of psychodynamic treatments, she noted. It should also motivate those who work with CBT and medication therapies to "do studies to verify the effectiveness of those treatments over the long term," Charles added.