Treating Panic Disorder: A Psychotherapeutic Case

| February 28, 2011 | 0 Comments

by Jason R. Collison, MD, and Terry L. Correll, DO
Dr. Collison is a Fourth Year Resident and Dr. Correll is Assistant Professor—Both from the Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Innov Clin Neurosci. 2011;8(2):33–40

Series Editor: Paulette M. Gillig, MD, PhD, Professor of Psychiatry, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Disclaimer: The case examples provided in the Psychotherapy Rounds series are composite cases used to illustrate teaching points and are not real patients.

Funding: There was no funding for the development and writing of this article.

Financial disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: Psychodynamic, psychotherapy, panic disorder

Abstract: Panic attacks are a common complaint of patients seeking psychiatric care. Treatment options for panic disorder include both medications and psychotherapy, either alone or in combination. Psychodynamic psychotherapy can be very effective in treating panic disorder, yet in recent years, psychiatric residency training has emphasized a medical model over teaching psychotherapy. In this article, we will use a composite case to illustrate how psychodynamic psychotherapy can be utilized to treat panic disorder in such a way that is rewarding for both the patient and the psychiatrist.

Introduction

The past several decades have been marked by an explosion of knowledge in the neurosciences. Psychiatric residency training has required residents to learn about an ever-increasing repertoire of psychoactive medications and the various neuroreceptors they influence. There has also been a surge in manualized psychotherapies that are amenable to research and fit well within today’s emphasis on evidence-based practices. Some authors have wondered if this would lead to the demise of psychodynamic psychotherapy training in psychiatric residency programs.[1–5] Other authors are concerned that residents are becoming less interested in psychodynamic psychotherapy,[6] and residents themselves have mixed feelings about the quality of training they receive in psychotherapy.[7] Yet, a new body of research in recent years supports the effectiveness of psychodynamic psychotherapy in an evidence-based fashion.[8] Some of the best work has come in the realm of treating panic disorder. In this article, we present a composite case using psychodynamic techniques and their effectiveness in treating panic attacks to illustrate how utilizing this theoretical approach can be profound for the patient as well as professionally rewarding for the psychiatrist.

Case Example: Initial Presentation

(Composite case; not a real patient). Eric was a 30-year-old, married, Caucasian man who sought psychiatric treatment for panic attacks that were plaguing him for the past year. During his intake session, he reported that the attacks began “out of the blue” about one year ago and that over the past three months they became more frequent. He described that hearing music often triggered a panic attack and that he started to alter his daily routine due to his worries about having a panic attack at an inopportune time. He described a scenario that recently occurred while commuting to work when a car pulled alongside him at a traffic light with loud music blaring. Eric said he was really bothered by the music and began to experience an abrupt onset of rapid breathing, shortness of breath, racing heart, trembling limbs, sweating, and a feeling that he was detached from the world. He managed to pull off the road where he waited for 20 minutes before his symptoms subsided. Eric was late for work and was written up by his supervisor, which never occurred previously during his entire career. In response, he altered his driving route to avoid as many traffic lights as possible, which added considerably to his morning commute, but effectively helped him to avoid similar encounters with music. As he described this series of events, his voice dropped in volume as he muttered, “It is so stupid that I can’t drive to work like a normal person.”

Practice Points

Eric presented with classic symptoms of panic disorder and sought help because his symptoms were interfering with his work. His symptoms were present for one year, yet were not so severe to cause him to seek help earlier. At the time of presentation, his attacks were escalating in frequency and starting to affect his ability to function. As the psychiatrist considered how to treat Eric’s panic attacks, he noted that there were several features in Eric’s initial presentation that suggested that he would be a good candidate for psychodynamic psychotherapy. First, Eric described how his panic symptoms started abruptly and that he did not identify any reason to help explain why the attacks began. In a psychodynamic model, we assumed that there was a reason(s) for why Eric’s symptoms started and that his description that they started “out of the blue” reflected how such information remains largely unconscious at initial presentation. In a psychodynamic approach, Eric’s psychiatrist formed a hypothesis that if Eric uncovered the unconscious reason or reasons for the attacks, it would help facilitate relief from his symptoms. This topic may be broached by expressing curiosity about the time when the panic attacks started. Eric’s psychiatrist may ask questions such as:

1. “When did you first realize that music could trigger a panic attack?”
2. “Can you tell me the first time you remember music causing you to feel this way?”
3. “Could you tell me more about the way you felt before you ever had a panic attack?”

As Eric’s psychiatrist collected a history about the events and emotional state that the patient experienced prior to the panic symptoms, he might discover numerous factors that influenced the onset of panic attacks. This information could then be formulated into an interpretation during Eric’s psychotherapy session.

Another clue that suggested Eric was a good candidate for psychodynamic psychotherapy was the change in volume of his voice, demonstrating an affective response, as he described the belief that the symptoms implied he was “not a normal person.” During this interaction, the psychiatrist noted that Eric felt sufficient rapport with his psychiatrist to allow him to express emotions that might be described as shame or embarrassment.

Before choosing a psychodynamic approach to treat a patient, a psychiatrist looks for signs that delving into emotionally charged material can be tolerated sufficiently so as not to destabilize the patient. In Eric’s case, the psychiatrist inferred that Eric was ready because he was at least comfortable enough to raise the topic when he said he was “not a normal person.” His psychiatrist could test this by commenting on what he observed during the interaction.
For example, a psychiatrist might ask the following questions:

1. “I noticed your voice became soft as you spoke about not feeling like a normal person. Could you tell me more about that?”
2. “Were you aware of how quiet you became when you said you didn’t feel like a normal person?”

Questions like this encourage the patient to not only be curious about his or her emotional state, but also help him or her to develop a heightened awareness of feelings. However, if the questions lead to significant worsening, such as dramatic decompensation between sessions or active suicidal thinking, then this type of exploration may be too painful and inappropriate at this time of treatment.

Finally, during this initial session, the psychiatrist noted that Eric’s panic attacks appeared to be situationally bound (i.e., there was an environmental trigger that preceded the individual attack). It is important to note that this environmental cue is not an actual danger; rather, the stimulus is something most would consider benign. The fact that Eric’s panic attacks were triggered by music entices one to wonder why something so common and enjoyable for most people created such misery for him. The psychiatrist expected that Eric must also have wondered why his experience was so and furthermore predicted that his own explanation likely led to feelings of being defective. The presence of the environmental trigger indicated that a psychodynamic psychotherapy would be helpful for Eric. If an unconscious process was causing music to elicit anxiety and panic attacks, then by helping Eric to understand the roots of the trigger would diminish its predilection to induce those symptoms. Understanding the meaning would also help relieve the feelings of “being defective” as the patient learned the psychological significance the cue serves. The opportunity to offer an interpretation to Eric, however, had to wait until the psychiatrist gained sufficient information to develop a reasonable explanation for why music triggered panic attacks in Eric.

Case Example, Continued: Initial Psychiatric History

Prior to seeking help from a psychiatrist, Eric informed his family physician that he was having symptoms of panic. His physician started him on fluoxetine and increased his dose appropriately every 6 to 8 weeks, reaching a final dosage of 80mg daily. He was also given lorazepam 0.5mg as needed for panic attacks. Initially, after starting fluoxetine, his panic attacks decreased in frequency. He was also able to use lorazepam to abort the few panic attacks that remained. However, Eric complained that lorazepam left him feeling tired and “numb” for several hours after taking it, thus he avoided its use on days when he had to work or drive. This regimen was sufficient until he had the panic attack while driving to work, resulting in his tardiness and reprimand. After this event, Eric had attacks several times per week and worried that medication alone would not solve his problem. He also reported that his anticipatory anxiety about hearing music had likewise increased since his reprimand. When he shared this perplexing trigger with his family physician, Eric was referred to the psychiatrist. Eric delayed the referral and instead tried talking to a counselor at his church for several weeks. He learned relaxation techniques and discussed his tendency toward “over-reaction” with this counselor. When Eric discussed how the music triggered his panic attacks, the counselor commented that it was “strange” and that he normally recommended listening to music as a way to facilitate relaxation. Eric ceased going to the counselor and came to see a psychiatrist because he reported that he felt desperate.

Practice Points

Eric’s psychiatrist was faced with a common problem in terms of how to treat Eric’s anxiety and panic attacks. Eric tried an appropriate selective serotonin reuptake inhibitor (SSRI) and was titrated to an effective dose for anxiety.[9] He initially experienced some relief; however, its effectiveness was not sufficient in the long term as a monotherapy. An abortive strategy for panic was attempted by using a benzodiazepine; however, the side effects from lorazepam interfered with Eric’s ability to function in several areas including work. Thus, the psychiatrist arrived at a common conundrum where medication alone failed to meet the patient’s needs.

There were several paths to consider before moving forward. One strategy would be to try Eric on another SSRI. The downside to this option was that it might require several months to cross taper and titrate to an effective dose for anxiety. Also, since fluoxetine initially appeared to be effective but then later was insufficient to control panic, the psychiatrist worried that Eric’s response to another SSRI might be similar. Another option was to choose an agent from a different class, such as a mixed mechanism antidepressant. This could potentially have had a better result; however, the evidence is unclear as to the likelihood of a better outcome, and nothing suggests that it would be more effective than psychotherapy. Psychotherapy has fared well against medications in panic disorder.[8,10–12] Increasing the dose of lorazepam was a poor option since Eric already had difficulties with side effects.

For these reasons, serious consideration was given to treating Eric’s panic attacks with psychotherapy. Advantages of treating panic attacks with psychotherapy are that it avoids multiple trials of medications and the risk of their potential side effects, extensive time to accomplish those trials, and psychotherapy provides a direct intervention to address Eric’s belief that he is defective. This last point is too often overlooked. Our culture, both in the clinical and nonclinical settings, has capitalized on the idea that mental illness is related to “imbalances” within the human brain. In the nonclinical setting, this message is reinforced by an onslaught of commercials for prescription medications, and in the clinical arena, physicians often narrow their explanations of patients’ symptoms and pathology as being due solely to neurochemical imbalances. Frequently, we see patients who believe their symptoms reflect some “defect” within their brain, and often that belief can be an additional psychological burden. Psychotherapy offers a beautiful opportunity to precisely address the core where symptoms originate and unburden the patient from the anguish of feeling abnormal.

Finally, of all the possible options to treat Eric’s panic attacks, only psychotherapy provided a way to specifically address the environmental trigger for his panic attacks. Eric raised the importance of his musical trigger several times, and the psychiatrist imagined how difficult it was for him to make sense of this. Eric’s psychiatrist was curious about the nature of this trigger beyond what was happening on a neurochemical level. This is how psychodynamic psychotherapy can be professionally rewarding. It allows the psychiatrist and the patient to enter into a quest to discover the underpinning for how a normal stimulus became a harbinger of fear and panic. This endeavor can be immensely rewarding for both individuals, the patient gaining deep understanding, symptom control, and further life mastery, while the psychiatrist gains understanding of his patient in a rare, profound way.
Advantages of choosing psychotherapy to treat panic disorder include the following:

1. Avoids multiple trials of medications
2. Avoids potential side effects of medications
3. Allows for a more meaningful explanation of symptoms
4. Likely to be at least as effective as medication
5. Provides a means of addressing environmental cues
6. Rewarding experience for the patient and psychiatrist.

Case Example, Continued: Panic History

Upon the recommendation of his psychiatrist, Eric elected to start weekly psychotherapy sessions. In an early session, his psychiatrist asked Eric to describe his first panic attack. Eric initially began talking about the panic symptoms he experienced. His psychiatrist gently directed him to describe the setting where panic first occurred. Eric remembered that he was at home with his wife in the afternoon and that his neighbor was building a shed in the backyard. He recalled that there were various hammering and banging noises from his neighbor that annoyed him. His neighbor then turned on his “boom box” and started playing music loudly while he worked. Just after the music started, Eric felt blood pounding in his head, his chest felt “tight and heavy,” his breathing became rapid, and he felt that he was “coming apart at the seams.”

Eric’s psychiatrist reflected, “That sounds very frightening,” then went on by saying, “I am curious if you remember what you were doing prior to that attack and how you had been feeling that day.”

Eric looked briefly startled, paused, then glanced down and said, “My wife and I were trying to plan our first vacation since our honeymoon. We were arguing because I wanted her to tell me where she wanted to go and what she wanted to do, and she kept replying, ‘Whatever you want will be fine.’ I didn’t want to make all of the decisions on my own, but eventually conceded to pick a location, the hotel, and the various activities. I felt worn down and tired after the argument and tried to relax by watching sports on TV, then the music from the neighbor started and I freaked out.”

After saying all of this, Eric was quiet and stared at the floor. His psychiatrist noted how upset Eric looked as he related the events of that day and said, “While you were telling me about planning your trip and the argument between you and your wife, you looked as distressed as you did when you described the panic attack earlier.”

Eric was quiet for several moments and then said, “I had forgotten about that fight,” while continuing to look at the floor.

His psychiatrist commented, “You look sad right now.”

Eric responded, almost to himself, “I think that was my first argument with my wife since we were married. I can’t believe I forgot that.”

After another pause he added, “It would be easier if it was only the music.”

Practice Points

In this early portion of Eric’s therapy, his psychiatrist encouraged him to recall the setting in which he first experienced a panic attack. Reliving panic attacks is part of the first phase of treatment described in Milrod’s book Manual of Panic-Focused Psychodynamic Psychotherapy.[13] The psychiatrist accomplishes this by guiding Eric away from the symptoms of panic, which were the first details Eric spoke about when asked about his initial panic attack. The emphasis is intentionally moved away from the symptoms of panic allowing Eric to recall details about the day that contributed to his state of mind prior to the panic attack. This underscores the importance of discovering the context and meaning attributed to the symptoms in psychodynamic psychotherapy. Eric was aware of his symptoms, but the context faded and potential meaning behind them were never consciously available to him. His psychiatrist helped him recall the forgotten context and moved beyond the symptoms by following Eric’s affect into previously unexplored areas. When discussing the history of the chief complaint, the psychiatrist should consider the symptoms, the context, and the meaning.

The amount of detail Eric recalled in this early session was impressive. Details may be initially few or vague about the context in which a panic attack first occurred; persistent exploration in psychotherapy will help uncover the context and meaning of the symptoms over time. Developing and deepening the therapeutic relationship will also help in this regard. Even though Eric recalled many important details about his first panic attack, he needed to revisit this topic multiple times throughout the course of treatment in order to integrate this experience into his understanding of his symptoms.

In psychodynamic psychotherapy, we assume that panic is a solution for psychological conflict. In this case, by taking the time to explore the first panic attack in depth, his psychiatrist searched for clues as to what the nature of the conflict may be. In Eric’s case, the psychiatrist now had evidence that his panic attacks were related to interactions with his wife. The exact nature of these dynamics were still unclear. As the psychiatrist began to discover these relational dynamics, it was important for him to share his observations with Eric in hopes that it would facilitate the patient’s curiosity about the role panic served in his life. The more Eric pondered about his reasons for having panic, the less likely he was to have an actual panic attack. In essence, by opening himself to learning about the unconscious reasons for panic, he was negating the function the panic serves, in this case allowing him to avoid conflicting feelings. As illustrated previously, Eric was beginning to understand that his panic attacks do not arise “out of the blue,” but are connected to stressors in his life. As Eric gained more awareness of these stressors, he had fewer panic attacks as they no longer served their psychological function of avoiding conflict.

Case Example, Continued: Developmental History

As Eric’s psychotherapy progressed, his psychiatrist learned that Eric was an only child from a middle class family. Eric’s initial description of his childhood was, “Fine, just like any other kid,” though he noted he was a quiet child. Relatively early in treatment, the psychiatrist discovered that Eric’s father had a short temper and was quick to yell at both his wife and his son, Eric. Eric’s mother, on the other hand, was described as “sweet and loving.” During the course of treatment, Eric’s psychiatrist discovered that Eric’s mother frequently deferred most decisions to her short-tempered husband. The volume of Eric’s voice tended to decrease as he discussed arguments between his parents.

In one session, Eric related that his father would often come home from work in a bad mood and expected everyone to “stay out of his way.” His father would complain about dinner if it was not to his liking and vent his frustration frequently toward Eric. He would make remarks such as, “That was a stupid thing to do,” while Eric was telling his mother about his day at school. Later, his mother would tell Eric, “Your father didn’t really mean what he said. He just had a bad day,” but never intervened when the comments were being made. Eric reflected that his mother, “probably should have left” his father, though he also noted, “I knew she never would leave him.”

Eric eventually said during the course of psychotherapy that he hated his father and secretly felt that his mother also hated him as well, but she stayed with him in marriage for the sake of their only child. He wished that his mother would have left his father and believed that they would both have been better off on their own.

Practice Points

Here we observe that Eric’s psychiatrist collected a detailed developmental history about the interactions between various family members. Obtaining a thorough developmental history is an essential part of psychodynamic psychotherapy, and here we see how this portion of the developmental history informs the psychiatrist about significant family interactions during Eric’s childhood. Eric’s psychiatrist would explore how this has shaped Eric’s pattern of interactions with others. Note how we see similar qualities of “deferring” in Eric’s mother and his wife. This symmetry could lead to a psychological conflict. On an unconscious level, Eric might have been worried that he would re-create the dynamics that existed between his parents in his own marriage. That possibility could be devastating as we also observe that not only did Eric have strong negative feelings about his father, but he believed that his mother also felt hatred toward his father. In this example, we may hypothesize that Eric unconsciously believed that feeling and expressing anger would cause his wife to hate him and that this intolerable outcome must be avoided at all costs. As the case goes forward, we will see how Eric works against this outcome by using the ego defense of denial to protect against his experience of anger, which if present, would make him “similar” to his father. In ways such as this, we see how learning about a person’s developmental history helps lead to insights about various psychological conflicts that are playing out in his or her life.

Case Example: Early Therapist Observations

Over the first two months of psychotherapy, Eric had fewer and less intense panic attacks. As he entered his third month of treatment, Eric had a panic attack the day prior to his appointment. He began the session looking distressed as he discussed having the attack the previous day and how it made him feel that he was not progressing. His psychiatrist inquired about the attack, and Eric described how the day before his appointment, he was at the mall trying on clothes and heard muffled music from a band that was playing outside of the store. Eric recounted how the music “really freaked him out” again. This was especially frustrating as he had recently felt he was improving and felt good earlier that day when he left home.

As Eric was describing these events, he stopped mid-sentence and said, “I just remembered something.” His psychiatrist looked curious and waited silently for him to go on. Eric continued, “My parents used to play music at night and it sounded the same way, rock ‘n roll that was muffled through the walls. It was usually on those days when my dad was in a bad mood. When I was older, I realized they were “doing it” and I would lie in bed and be so pissed that my mom would have sex with him when he was such a jerk earlier in the day.”

Eric looked both animated and stressed; his hands were clenched into fists and his voice was raised as he recounted this. His psychiatrist said, “That sounds very important in light of what we have been talking about in our sessions,” to which Eric replied, “Yeah…I guess that would explain a lot of the music stuff.”

Eric sat quietly for several minutes until he said, “I was thinking about how frightened I have been of music.”

His psychiatrist commented, “While you were talking, I was struck by your voice and body language. Are you aware that you look angry rather than fearful?”

Practice Points

It is common for patients to feel frustrated whenever a panic attack occurs during the course of psychotherapy. In this example, after experiencing some initial improvement, Eric had a panic attack causing him to feel he was not moving forward anymore. In psychodynamic psychotherapy, when this type of scenario arises, the psychiatrist may wonder what has happened to cause symptoms to flare up again. In this particular case, Eric became more aware of the factors that influenced his symptoms and noted that his panic was unexpected as it occurred at a less stressful time. Functioning like his own psychotherapist, Eric’s mind examined the environmental trigger, which subsequently led to his revelation about the origin of why he is bothered by music. Had Eric not explored the subject so well on his own, his psychiatrist would have done well to dig deeper at this time.

Another important interaction occurred when his psychiatrist commented on Eric’s affect during the session. Freud first described anxiety as being primarily related to the sexual drive. In modern times, we have moved away from thinking anxiety is solely due to sexual wishes and now recognize its importance in relation to fear. However, the fear is often not the only motivating force in panic. Milrod’s Manual of Panic-Focused Psychodynamic Psychotherapy[13] notes how commonly anger can be a central theme for panic attacks. Often, the anger is unconscious and a panic attack can serve as a means of denying anger. The practitioner treating panic with psychodynamic psychotherapy must be observant for clues that anxiety and panic attacks are the patient’s way of avoiding angry feelings. Here, the psychiatrist pointed out that while Eric was discussing fear, his affect appeared angry.

Case Example: Therapist Interpretation

Following his panic attack at the mall, Eric was free from panic attacks for several months and reported he was less bothered by music. One day, Eric came into session looking distraught and said, “After all of this time, I had another attack. A car drove by our house with music blaring and I got so worked up it took over an hour before I felt normal again. What can I do to make these attacks finally stop?”

Eric’s psychiatrist replied, “With past attacks, we have been able to discover factors that contributed to how you were feeling when your panic symptoms started. I wonder if you are aware of anything that may have contributed to this panic attack?”

Eric sighed and remembered, “My wife and I were going to go to the movies, and I kept asking what she wanted to see. Her reply was the same as always, “Whatever you want.’”

Eric’s psychiatrist commented after a brief silence, “I noticed that the circumstances for this attack are very similar to the first panic attack you ever had. Your wife and you were having trouble making decisions together. In both cases, your wife seemed to be deferring to you.”

Eric nodded and said, “Sometimes I wish she would just say what she wants.”

Eric’s psychiatrist replied, “I wonder if her behavior ever reminds you of your own mother.”

Eric looked startled and said, “What do you mean?”

His psychiatrist went on, “As you were speaking about your wife, it reminded me of how your mother allowed your father to do as he pleased, often at your expense. I am curious if you ever considered how your wife and mother behave similarly.”

Eric looked down and said, “Yeah, they can both be passive.”

His psychiatrist then offered the following interpretation, “I have wondered if you worry that you are recreating your parents’ relationship.”

Eric looked down again and said nothing. His psychiatrist added, “It may be that having panic attacks feels safer than being angry at your wife.”

Eric whispered, “I don’t want my wife to hate me.”

The psychiatrist said, “I can imagine that hearing music reminds you of the dysfunction between your own parents and stirs up your anger about what you went through as a child. It must be very difficult to allow yourself to be angry because as a child, you saw how hurtful your father’s anger was, and how powerless your anger as a child was to change the situation. I think you had this particular panic attack because all of these elements came together again. Your wife’s passivity reminded you of the quality you like least in your own mother and you were angry at your wife for doing this. And if that wasn’t enough, you heard the music that triggers the painful memories of your mother giving into your father when he was in a bad mood. As much as you dislike the panic, I imagine it is less painful than having to deal with all of those other emotions at the same time.”

Eric did not say anything for a while. Eventually he said, “That makes sense when you put it like that, but it’s hard to process. I don’t know how I’m going to remember it all.”

Practice Point

Here we witness Eric’s psychiatrist offering an interpretation linking the origin of his panic attacks, the eliciting trigger, and the psychological function served. When Eric first started in psychotherapy, it appeared as if the music alone was enough to elicit a panic attack. As treatment progressed, Eric had fewer attacks and the role of music diminished. However, unexpectedly for Eric, another panic attack occurred. As his psychiatrist noted, this particular attack occurred in a similar context to Eric’s very first panic attack. Eric seemed on the verge of putting all the pieces together on his own. He was not only aware of the musical trigger, but also was quickly able to assess his emotional state and how it related to the interaction with his wife. His psychiatrist helped link those pieces together as well as pose the idea that Eric feared he was recreating his parents’ relationship.

The choice of when to offer an interpretation in a dynamic therapy can be challenging for the psychiatrist. However, when treating panic disorder with psychodynamic psychotherapy, panic attacks can serve as a marker as to when an interpretation may be useful. Early in treatment, when attacks are more frequent, the psychiatrist’s role may only be to follow the patient’s affect from the surface to deeper levels so that dynamic relations can be discovered. Now, later in treatment and with panic attacks now uncommon, this recurring panic attack may signal that the pieces of the puzzle have once again come close together and are almost begging to be interpreted. The psychiatrist was aware that Eric had been free from panic attacks for a meaningful period of time and correctly concluded that the recurrence of an attack must be due to a coming together of dynamic factors, otherwise, Eric most likely would not have experienced an attack at all. The psychiatrist used this opportunity to help Eric see the different components of his attacks as well as delve deep into a formulation that included a hypothesis that Eric feared he would become his father.

Case Example: Panic After Interpretation

Eric talked about his most recent panic attack as well as past panic attacks during the next several weeks of therapy. He also told his psychiatrist that he started talking to his wife about how he gets angry at her sometimes. This was very difficult for him to share with his wife but was also helpful. He said that his wife laughed at the idea that she would hate him. While this initially annoyed Eric because he did not feel she was taking him seriously, he later admitted that he took comfort in the way his wife reacted to the idea as if it were ridiculous. At other times, he described how he got annoyed that his wife frequently asked if she made him angry.

Eric told his psychiatrist, “I’m usually not angry at all until she asks, but once she does, it irritates me.”

Eric also told his psychiatrist about several occasions where he heard muffled rock ‘n roll music and did not experience any panic symptoms. Moreover, he was not even aware there was music playing until his wife mentioned it afterward. Several months later, Eric started wondering if his gains were permanent or if he would have to remain in therapy indefinitely to prevent panic attacks.

Final Thoughts

In this last portion of our case, we see evidence of a shift within the therapy. In the sessions following the interpretation offered by his psychiatrist, we see that Eric reexamined his panic attacks in a way that led toward meaningful change. He appeared more comfortable exploring his own anger and allowed this once “unacceptable” emotion to be discussed both in psychotherapy and at home with his wife. Eric learned that his wife’s love for him was unwavering despite his anger. We also observe that music no longer had the power to trigger panic attacks, and slowly, Eric’s hypervigilance for music dissipated. Overall, Eric experienced one of the primary benefits that psychodynamic psychotherapy has to offer. Namely, rather than simply achieving symptom relief, Eric was able to more accurately assess himself and the world he lived in resulting in meaningful change. Eric’s psychiatrist inferred that his interpretation was significant due to the change in symptoms and understanding that emerged in the sessions that followed.[13] In the sessions that would follow, Eric’s psychiatrist began to explore Eric’s curiosity about the permanence of his change. This was appropriately explored in the termination phase of treatment, upon which Eric seemed ready to embark.

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Category: Anxiety Disorders, Past Articles, Psychiatry, Psychology, Psychotherapy Rounds

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