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Personality Disorders in the Elderly

February 26th, 2007 by Dr. Bromberg

Dr. Robert C. Abrams of New York Presbyterian Hospital/Weill Cornell Medical College and I have co-authored a piece on Personality Disorders in the elderly. It is included in the February 2007 issue of Psychiatric Annals, as part of a focus on Personality Disorders (“Examining the issues and controversies surrounding diagnosis and treatment” is the issue’s subheading). I’m looking forward to reading the rest of the articles in the journal. Working and writing with Dr. Abrams has been a pleasure, and I encourage anyone who works with the geriatric population to buy his book, Personality Disorders in Older Adults: Emerging Issues in Diagnosis and Treatment.

I am including in this post a .pdf copy of the article (actually, it’s a late draft of the article – some corrections were made prior to publication). You can download it by clicking here. As with my last post, if I am in violation of any copyright regulations, and that is cause for complaint to anyone, please tell me so that I can remove the file. Otherwise, please have a look! Your feedback and comments are welcome.

Empircal evidence that psychodynamic psychotherapy works for panic disorder

February 21st, 2007 by Dr. Bromberg

In case you missed it, an important study has just come out of the Weill Medical College of Cornell University, demonstrating the success of short-term exploratory psychotherapy for patients with panic disorder. For those of us who believe in the value of dynamically-oriented work, this bolsters the argument that cognitive-behavioral treatments are gaining dominance not because they are better treatments, but because CBT researchers have been far more successful in publishing empirical evidence of their treatments’ efficacy.

Some of you may have access to the online archives of the American Journal of Psychiatry. If so, you can click here to read the paper detailing the study. Others may have a membership to the NY Times online, allowing you to read Benedict Carey’s recent article about the study. But for those of you with neither of the above, here is the full text of Carey’s article. (If reprinting this here is a copyright violation of any sort, it’s news to me. However, I will be more than happy to remove the text if a request is made.)

February 6, 2007

In Rigorous Test, Talk Therapy Works for Panic Disorder

By BENEDICT CAREY

   

The field of psychoanalysis has struggled with a disabling internal conflict in recent years: whether to subject the therapy to rigorous testing, like the process through which new drugs are approved, or to insist that the insights it provides are self-evident and cannot be put under a microscope.

This internal debate has raged even as analysis, Freud’s open-ended talking cure, has become increasingly marginalized as a practice. But the ground rules may soon change.

Last week, a team of New York analysts published the first scientifically rigorous study of a short-term variation of the therapy for panic disorder, a very common form of anxiety. The study was small, but the therapy proved to be surprisingly effective in a group of severely disabled people.

The paper, which appeared in psychiatry’s flagship journal, The American Journal of Psychiatry, is one of the most significant steps in a small but growing effort to study how this so-called psychodynamic therapy works, and for whom.

The brand of therapy tested relies on core tenets of analysis, like the search for the underlying psychological meaning of symptoms. But unlike traditional psychoanalysis, it focused on relieving symptoms quickly, and was time-limited. Previous studies of similar approaches have shown some promise for other disorders, like depression.

“It is very exciting, because you rarely see this kind of therapy studied at all, and it was very rigorously done,” said Dr. Dianne Chambless, a professor of psychology at the University of Pennsylvania who was not involved in the study but is now collaborating with the researchers.

Dr. David H. Barlow, a psychologist at Boston University, said in an e-mail message that the study was too small to be conclusive but that “the authors should be congratulated for actually taking the first step in doing the hard work of beginning to evaluate treatments” that are widely used without good supportive evidence.

The researchers tested a pared-down version of analysis tailored specifically for panic attacks, the breathless, paralyzing dread that strikes some 1 percent to 2 percent of people, seemingly out of nowhere. Previous studies had found that other kinds of therapy — including exposure techniques, in which people learn to diffuse their anxieties by facing them one small step at a time — can relieve panic attacks in half to two-thirds of patients, depending on the severity and type of anxiety.

In the new experiment, Dr. Barbara L. Milrod, a psychiatrist at Weill Medical College of Cornell University, led a team of therapists who treated 49 men and women with a variety of anxieties. Some were agoraphobic, unable to ride the subway or visit certain parts of town. Others had symptoms of depression or of personality problems, like a disabling dependency on other people or an avoidance of social situations.

Half of the group received a form of relaxation training, in which they learned how to moderate their arousal by tensing and relaxing specific muscle groups. The other half received psychodynamic therapy, working with their therapist in two weekly sessions to understand the underlying meaning of their symptoms — when the reactions first started and how they might be linked to loss, broken relationships or childhood experiences that unconsciously haunted their current lives.

After 12 weeks, 39 percent of those working with relaxation techniques improved significantly on standard measures of anxiety and reported fewer panic-related problems in their relationships and work. But almost three-quarters of those receiving psychodynamic therapy reported similar benefits.

“This is best response rate I’ve seen in a controlled trial for panic,” Dr. Milrod said. “And the therapy was time-limited. I don’t think anyone would care if psychoanalysis cured panic in six years — snore. We wanted to know that what we were doing worked, that it wasn’t malpractice.”

Researchers from Columbia University, the Mount Sinai School of Medicine and Hunter College were also involved.

Studies of this brand of therapy are important for the thousands of therapists around the world who mix and match analytic techniques with other therapies. One former patient treated with this therapy began to have panic attacks after witnessing a young woman die of an illness, said her doctor, Fredric N. Busch, a Cornell psychiatrist and a co-author of the new study.

The patient, who was not a part of the study, described the death as deeply unfair, and in sessions explored perceptions of unfairness in her work and her life, including her childhood. “Once she was able to understand this pattern, the panic became less frightening, she felt safer and was eventually able to get rid of the symptoms,” Dr. Busch said.

The researchers said that even if this approach was not for everyone, it appeared to be especially beneficial for a particular group. In an analysis of individual patient’s responses, the researchers found that those who also had a personality disorder, like avoidant personality, showed significantly greater improvement than those whose symptoms were related solely to anxiety. Patients with multiple diagnoses are usually more difficult to treat.

“This finding was very surprising and there’s absolutely no precedent for it, as far as I know,” Dr. Milrod said.

Correction: February 8, 2007

An article in Science Times on Tuesday about a study finding that talk therapy is an effective treatment for panic disorder misstated the credentials of two experts quoted. The researchers, Dianne Chambless of the University of Pennsylvania and David H. Barlow of Boston University, are psychologists, not psychiatrists.

StoryCorps’ Memory Loss Initiative

February 4th, 2007 by Dr. Bromberg

For those of you who haven’t heard of StoryCorps, it is a Brooklyn-based organization whose mission is to record and archive everyday people’s stories. There are recording booths at Grand Central Station and at Ground Zero, and also mobile booths which travel around America.

 As psychotherapists, using conversation as a means of helping and healing is fundamental to our work. For this reason alone, I believe we should all take notice of what StoryCorps is doing: Their message is that people’s stories matter, and that the process of interviewing and being interviewed leads to unexpected and valuable insights.

Their latest project, the Memory Loss Initiative, aims to provide an opportunity to hear and to preserve stories that may otherwise be lost. More importantly, it may help to create an environment of curiosity and interest between loved ones at a time when the relationship may be strained by confusion, frustration and fear. Guidelines for interviewing people with memory loss are provided, as well as a “special questions” list.

Welcome

February 4th, 2007 by Dr. Bromberg

Hello, everyone! I’ve started this blog as a way of exploring the numerous professional resources here in our backyard. Westchester County is home to exceptional clinicians, programs, and agencies, and I hope to talk with and find out about as many of them as I am able.

 I will share what I learn here. I encourage you to add your comments and questions as often as you like. Suggestions and corrections are welcome, too!