March 5, 1999

By Salvador M. Guinjoan, M.D., Ph.D.

A conflict has arisen between APA and the American Psychoanalytic Association regarding the APA treatment guideline for panic disorder, which appeared last May. I believe the debate has implications that go well beyond specific considerations of panic disorder treatment, reflecting tensions that affect psychiatry in general and our identity as psychiatrists in particular. This issue should interest psychiatry residents, who will shape the way psychiatry will be conceptualized and practiced in the future.

The psychoanalytic association believes that insufficient recognition is given in the practice guideline to psychodynamic psychotherapy in the treatment of panic disorder. The practice guideline places a particular emphasis on treatments whose efficacy is supported by studies with carefully defined groups of patients, treatment interventions, and outcomes and therefore replicable findings. Personal experiences based on subjective clinical impressions (even if they come from experts) do not occupy the preeminent place assigned to controlled studies. Thus, less importance is attached to the subjective value of certain clinical observations, as compared with those derived from controlled clinical trials. My contention is that due to the very nature and origin of psychoanalysis and psychodynamic psychotherapy, it is unlikely that this kind of evidence will ever be found to support these forms of treatments, and yet they are valuable in the clinical management of patients.

In the book Psychodynamic Psychiatry in Clinical Practice, published in 1994 by the American Psychiatric Press, Glen Gabbard, M.D., states that psychodynamic interventions are guided, in general, by a principle that is opposed to the supposedly atheoretical, symptom-based approach of descriptive psychiatry. An emphasis on the latter approach is to be found in the APA practice guideline for the treatment of panic disorder and similar guidelines. What is important in the descriptive approach to psychiatric disease is the set of features shared by all patients allocated to a certain diagnostic category. Characteristics unique to each patient are considered peripheral to the essence of diagnosis, which usually must be based on observable behavior. Accordingly, such diagnosis will be matched with a relatively uniform treatment, potentially applicable to most or all patients in the group. In contrast to this view, or even better, complementing it, a psychodynamic approach takes into account those characteristics that are unique to each patient, that is, the ways in which a particular patient differs from all others (including those in the same descriptive category), usually by virtue of a life story like no other. Asserting that there is a need for an empirical, replicable validation of clinical interventions that rely upon the subjective (and, by definition, nonreplicable) interaction of two unique persons is a paradox that, albeit seemingly obvious, is repeatedly evoked by some authorities to discredit psychodynamic psychotherapy.

For example, Sara Charles, M.D., is reported in the October 16 issue of this newspaper to have stated that "the problem with psychodynamic psychotherapy is the evidence isn't there." Inherent in this assertion is the potential, erroneous assumption that, since there is no measurable evidence to support the benefit of psychodynamic psychotherapy, the technique is not beneficial, or at least its use is not justified.

Psychodynamic psychotherapy is a body of knowledge whose findings cannot be easily measured and reproduced, and whose transmission to new generations of psychiatrists depends on personalized, case-by-case teaching and supervision. I believe the consideration of the subjective phenomena that make each patient unique enriches whatever understanding we may acquire by using descriptive criteria and guides a qualitatively different set of interventions that complement those that may be applicable to all patients sharing the same diagnosis (in the case of panic disorder, cognitive-behavioral therapy and/or antipanic drugs). They are part of what is broadly referred to as the "art" component of psychiatric diagnosis and treatment, which, as described by Dr. Melvin Lewis in his classic Textbook of Child and Adolescent Psychiatry, is to be acquired by means of "supervision and continuous case conferences with acknowledged experts." He also quotes an elegant definition of psychodynamic psychotherapy by Victor

Raimy: "Psychotherapy is an undefined technique applied to unspecified cases with unpredictable results. For this technique, rigorous training is required." Therefore, most evidence about the efficacy of psychodynamic psychotherapy is to be found in "anecdotal" reports.

In sum, my contention is that the value of psychodynamic psychotherapy is probably to be found in the clinical wisdom of experienced teachers who share their knowledge with new generations of psychiatrists, even when results cannot be measured and replicated. Psychiatrists will have to decide whether this body of knowledge is valuable, especially as compared with treatments such as pharmacotherapy and short-term "manualized" psychotherapies. That said, I would like to note that the main payers for psychiatric services, including managed care companies, are perhaps already deciding for us in this important matter by not reimbursing psychiatrists for psychodynamic interventions and by restricting payment to the so-called evidence-based treatments referred to above. To put it in the words used by Dr. Harold Pincus (a member of the committee overseeing the development of APA's guidelines), "In the absence of standards, what is cheapest is best. . . . Evidence-based guidelines developed by professional organizations assist clinicians in asserting professional values in the face of economic pressures."