Does Manualized Psychodynamic Psychotherapy have an Impact on Youth Anxiety Disorders?
Publication: American Journal of Psychotherapy
Abstract
An open, pilot clinical trial of Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP), a 24-session, 12-week, manualized psychodynamic psychotherapy, was conducted in 10 patients, ages 8 to 16 years with primary generalized anxiety disorder (GAD), social phobia, and/or Separation Anxiety Disorder. Study benchmarks, including inclusion/exclusion criteria, outcome measures, and definitions of response were designed to match those of the Child/Adolescent Anxiety Multimodal Study (CAMS). The goal was to determine whether or not dynamic therapy has a clinical impact on CAMS subjects. Eligible patients were treated in 12-week, twice-weekly psychodynamic psychotherapy sessions. There was one dropout. Subjects improved across all measured outcome domains at treatment termination, and results were sustained at six-month no-treatment follow up. Child and Adolescent Anxiety Psychodynamic Psychotherapy merits further testing, and may be a promising alternative treatment for youth anxiety disorders.
Introduction
Anxiety disorders are the most prevalent group of psychiatric disorders, especially among youth, and they carry substantial morbidity (Kessler et al, 2006). Providing efficacious treatment options for youth with anxiety disorders can reduce suffering and impairment and can substantially impact public health, both in pediatric populations, and among future adults (Manicavasagar et al, 2010). Studies of Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) demonstrate efficacy for childhood anxiety disorders, including Generalized Anxiety Disorder (GAD), Separation Affective Disorder (SAD), and Social Phobia ([SP] Walkup et al, 2008; Silverman et al, 1999; James et al, 2005; In-Ablon et al, 2007). Nonetheless, despite clear efficacy of antidepressants, many parents are reluctant to have their children take them, and CBT is not always available or readily embraced by psychotherapy providers and patients (Khanna et al, 2010; Shafran et al, 2009). Furthermore, a significant group of patients do not respond to CBT and medications (Walkup et al, 2008; Ginsburg et al, 2011). Current evidenced-based, tested, efficacious psychotherapies for youth anxiety have focused on exposure and response prevention (Graham et al, 2011).
The current study was designed to assess the feasibility of a time-limited manualized psychodynamic psychotherapy for treatment of children and adolescents ages 8 to 16 years with primary GAD, SP, and/or SAD. This ubiquitous, yet unstudied, treatment targets mechanisms surrounding separation sensitivity, dyadic attachment, transference, and recognition of unconscious fantasies—all distant from the focus of CBT on exposure and response prevention (Busch et al, 2012). Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP) is a modification of Panic-Focused Psychodynamic Psychotherapy-eXtended Range ([PFPP-XR], Busch et al, 2012; Milrod, Shapiro et al, 2012), the best-tested manualized form of psychodynamic psychotherapy for adult anxiety disorders, which has shown efficacy for panic disorder in adults (Milrod et al, 2007).
Method
An open clinical trial was designed to match entrance and outcome criteria established in the Child/Adolescent Anxiety Multimodal Study (CAMS), the current benchmark study in this population (Walkup et al, 2008). From October, 2010 to October, 2012 ten subjects between the ages of 8 and 16 years were recruited at the Weill Medical College of Cornell University Department of Psychiatry. Subjects signed informed written assent and their parents signed informed written consent forms; the protocol was approved by the Weill Medical College Internal Review Board. Patients were admitted to the study if they met DSM-IV criteria for primary GAD, or SP, or SAD on the Anxiety Disorder Interview Schedule Child-Parent version (Albano, Silverman, 1996) at a minimum level of 5/8 (impairment [as measured by an ADIS severity rating. 4/8 = meets full criteria for the DSM-IV disorder; 5/8 = meets criteria for the disorder, and it causes significant life impairment]. Exclusion criteria were substance dependence, psychosis, bipolar disorder, mental retardation, acute suicidality, and organic mental disorders. Subjects with comorbid attention deficit disorder and/or depression were included. Subjects were eligible for inclusion if they were on stable (for at least two months’ prior to study entry) doses of daily medication, and if they agreed to keep their medications constant throughout the course of the trial. Medication, when present, was managed by a study psychiatrist to ensure that stable doses were maintained. Subjects were evaluated for symptoms of anxiety on the Pediatric Anxiety Rating Scale (PARS,RUPP, 2002), the primary outcome measure, as well as on the Children’s Global Assessment Scale ([C-GAS] Shaffer et al, 1983), and Clinical Global Impression–Severity (CGI-S) and Improvement (CGI-I) Scales (Guy, 1976). Diagnostic and severity ratings assessments were administered before treatment, at treatment termination (after 12 to 14 weeks of therapy), and at six-month follow up (no treatment was offered during the follow-up period) by a trained, reliable project coordinator who had masters’ level education.
Therapy
Child and Adolescent Anxiety Psychodynamic Psychotherapy is a 24-session, 12-week psychodynamic psychotherapy developed by Drs. Milrod and Shapiro, authors of the original Panic Focused Psychodynamic Psychotherapy (PFPP) Manual (Milrod et al, 1997), and Drs. Fonagy and Target, developers of Mentalization Based Therapy [MBT] (Bateman and Fonagy, 2009). Child and Adolescent Anxiety Psychodynamic Psychotherapy was designed to capture aspects of the best-studied and manualized forms of dynamic therapy. Child and Adolescent Anxiety Psychodynamic Psychotherapy focuses on decoding emotional meanings of anxiety symptoms and uses transference interpretation to illustrate conflicts of separation and attachment in understanding anxiety. Table 1 outlines treatment strategies used in CAPP.
| Anxiety Disorder Features | Dynamic Theory in CAPP | Target Symptoms and CAPP Strategies |
|---|---|---|
| Social Phobia | Extreme self consciousness and fears of embarrassing oneself are linked to conflicted wishes to be the center of attention and laced with guilt and self-punishment; normal desire for attention feels unacceptably aggressive, linked to fears of abandonment | Explore defenses against conflicted wishes to stand out, patients’ overly critical evaluation of others as entrée to connections with uncomfortable competitive wishes and conflicted, unacceptable aggression. |
| GAD | Extreme inability to relax, hypervigilance, and dread of many life situations arises from conflicts related to personal meanings of curiosity and exploration of new situations; normal curiosity and desire for exploration is associated with feeling dangerously alone, out of control and overwhelmed. | Focus on terror of internal urges, including aggression and conflicted desire for autonomy. Emerging fantasies actively connected with symptoms and persistence of anxiety. |
| Separation Anxiety | Severe, developmentally inappropriate separation distress arises from conflicts between normal strivings for autonomy and concerns about hurting or infuriating the emotionally-needed parent. Clinging to parent leads to anger at parent and self; normal strivings for autonomy are associated with feeling unacceptably lonely and frighteningly rejecting of the parent. | Explore transference, an emotionally vibrant paradigm for understanding and altering separation fears. Intensity (2x/week) and brevity (12 weeks) are key CAPP aspects making decoding emotional significance of termination central to the final third of treatment. |
| Anxiety re.establishing age appropriate autonomy, common to these disorders | Conflicts and fears about normal autonomy (i,e. growing wish to manage by oneself, curiosity and independence) common in SP, GAD, and SAD patients emerge in transference. Assertiveness (seeking attention, exploring and attempts at independence), perceived as destructive anger, creating conflict. | CAPP focus on transference highlights conflicts about autonomy, especially as incorporated into fantasies of bodily harm; sense of inadequacy is experienced as physical anxiety and symptoms. |
| Comorbid depression-when present | Conflicted aggression leads to guilt and negative self-evaluation, depressive symptoms, and somatic anxiety | CAPP focus on conflicted aggression detoxifies and helps patient redirect it, improving autonomous function and assertion. Mitigates guilt, with improvement in autonomy, negative views of self improve. |
Therapists
All were experienced child psychiatrists/dynamic clinicians who all underwent an eight-hour training course in CAPP. Mean length of clinical experience: 14 years post graduate.
Therapist Adherence to Protocol. Two trained psychotherapist-adherence raters evaluated therapist observance of the CAPP manual protocol. Three tapes of full sessions from early, mid, and late treatment phases for each patient were selected randomly (using a random-number program) and scored. To assess inter-rater reliability, 10% of the rated tapes were randomly selected to be independently evaluated by both raters. The scale used was the 8-item CAPP Adherence Rating Scale (available from the authors) that reliably describes major aspects of CAPP. Key components are: determination of degree of anxiety focus, and exploratory, nondirective, and dynamic technique. In order to meet adherence standards, study therapists must have achieved ratings of ≥4 (on a scale of 1 to 6) for six of eight adherence items in each of three rated sessions (one from each third of treatment). Therapists sustained adherence standards for CAPP in our current open trial. Mean therapist adherence rating = 5.8. Four raters determined reliability of the scale, with mean inter-rater ICC 0.92 (N = 50).
Patients
Twenty four patients were evaluated on the Anxiety Disorders Interview Schedule-Child-Parent version [ADIS-C-P] for study inclusion. Thirteen did not meet study criteria: One patient had primary dysthymic disorder; one patient had a neuropsychiatric disorder (pseudoseizures); five did not have severe enough anxiety to meet entry criteria, two had primary PTSD, one had primary panic disorder, one had primary major depression. In one instance, the family reconsidered having the child in a research study. Eleven subjects were accepted to the study. One withdrew before meeting the therapist due to scheduling concerns. There was one dropout after session 6; the parents felt the child had improved and were unwilling to continue sessions or assessments.
Results
The ADIS diagnostic data are presented individually in Table 2, to give the flavor of multidimensional impairment and demonstrating improvement that was observed as many subjects had significant comorbidity. All subjects lost their primary diagnoses by treatment termination. Symptomatic and psychosocial improvement data are summarized in Table 3 at the three observational time points.
| ID | time | ADIS-GAD | ADIS-SP | ADIS-SAD | ADIS-DD | ADIS-PTSD | ADIS-PD | ADIS-Ag |
|---|---|---|---|---|---|---|---|---|
| 1 | pre | 6 | 5 | 4 | ||||
| post | 1 | 2 | 4 | |||||
| f/u | 2 | 0 | 1 | |||||
| 2 | pre | 6 | 5 | 4 | ||||
| post | 3 | 4 | 0 | |||||
| f/u | 0 | 0 | 0 | |||||
| 3 | pre | 4 | 4 | 3 | 3 | |||
| post | 1 | 0 | 1 | 0 | ||||
| f/u | 0 | 0 | 0 | 0 | ||||
| 4 | pre | 5 | 4 | 3 | ||||
| post | 3 | 2 | 1 | |||||
| f/u | 0 | 1 | 0 | |||||
| 5/dropout | pre | 4.5 | ||||||
| post | dropout | |||||||
| f/u | ||||||||
| 6 | pre | 5.5 | 2 | |||||
| post | 2 | 1 | ||||||
| f/u | 2 | 1 | ||||||
| 7 | pre | 5 | 5.5 | 4 | ||||
| post | 0 | 1 | 0 | |||||
| f/u | 0 | 0 | 0 | |||||
| 8 | pre | 7 | 4 | 4 | 6 | |||
| post | 1 | 0 | 2 | 0 | ||||
| f/u | 1 | 0 | 1 | 0 | ||||
| 9 | pre | 5.5 | 7 | 4 | ||||
| post | 2 | 3 | 2.5 | |||||
| f/u | 0 | 0 | 0 | |||||
| 10 | pre | 5.5 | 7 | |||||
| post | 5 | 3 | ||||||
| f/u | 2 | 1 |
ADIS diagnostic categories are defined out of possible severity ratings of 8 (most severe), with 4 indicating “meets DSM-IV criteria for the disorder ” and 5 indicating impairment from the disorder. The primary disorder is in bold.
| Age | PARS | CGAS | CGI | |
|---|---|---|---|---|
| Baseline | 12 (2.7) | 21.0 (4.3) | 55.5 (7.4) | 5.3 (.9) |
| Termination | 7.6 (4.6) | 80.1 (7.1) | 3.9 (1.2) | |
| F/U | 6.7 (7.0) | 81.1 (9.3) | 3.1 (1.6) | |
| P (pre/post) | .0012 | .0008 | .04 | |
| Cohen’s D | 2.3 | -2.81 | 1.04 | |
| r | 0.1865 | 0.274 | 0.178 |
Discussion
Substantial, statistically significant, clinically meaningful improvements were observed across all measured outcome variables including degree and severity of anxiety symptoms, as captured on the PARS, the primary outcome measure, and in general global function. It was heartening that therapeutic gains were maintained at six-month no-treatment follow up. Furthermore, while significance testing in N = 9 would be inappropriate in the setting of such a wide range of presenting psychiatric diagnoses on the ADIS, it is promising that subjects generally lost their presenting and most comorbid diagnoses, and that these gains were maintained at 6 month no-treatment follow up. In general, patients improved from being quite clinically impaired to functioning normally after this 12 week psychotherapy-only intervention. These changes are reflected in the very large within group Effect Size changes observed. The limitation of the study is that it is a very small, uncontrolled clinical trial.
Conclusion
Despite the small sample size and the uncontrolled nature of the study, it appears that CAPP is promising and may warrant further systematic evaluation.
Funded by grants from the American Academy of Child and Adolescent Psychiatry, The American Psychoanalytic Association’s Fund for Psychoanalytic Research, the International Psychoanalytic Association, and a Fund in the New York Community Trust established by DeWitt Wallace. Dr. Milrod reports royalties from Taylor & Francis.
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Published in print: 2013, pp. 309–411
Published online: 30 April 2018
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