In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy.

Abstract

In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. Clinical Impact StatementQuestion: Does patient in-session emotional expression in an anxiety-focused psychodynamic psychotherapy facilitate symptom relief and developing the capacity to understand the psychological meanings of symptoms? Findings: Degree of patient emotional expression across three early sessions of panicfocused psychodynamic therapy predicted higher panic symptom improvement and symptom-specific mentalizing improvements subsequent to those early sessions. Meaning: Therapeutically facilitating a patient's ability to affectively explore and engage with meanings and conflicts surrounding symptoms may be a part of a good process in panic-focused psychodynamic therapy. Next Steps: Emotional engagement at particular moments, such as exploration of attachment-related relationship episodes and fantasies, may be particularly important in this treatment.

Reflective Functioning in Children and Adolescents With and Without an Anxiety Disorder

“…Thus, working on RF capacities within the therapeutic relationship could help patients develop insights about their thoughts and feelings when exposed to interpersonal situations and develop better regulation strategies as they learn to tolerate internal states that were previously uncomfortable. This is in line with research findings among patients with panic disorder revealing that higher emotional expression in patients during therapy leads to a greater reduction of symptoms ( Keefe et al, 2019 ). In summary, the present study suggests that clinical work with anxious youths should go beyond fostering mentalizing abilities to support and promote the development of emotion regulation strategies and resiliency, which are usual components of MBT ( Midgley et al, 2017 ; Achim et al, 2020b ).…”

“…This also suggests that RF difficulties among clinically anxious individuals would be specific to certain tasks or contexts and intrinsically related to the nature of their anxieties. In that, our results support the relevance of the corpus of studies focusing on symptom-specific RF in clinical populations (e.g., Kullgard et al, 2013 ; Keefe et al, 2019 ; Solomonov et al, 2019 ). Symptom-specific RF refers to the capacity to reflect on the psychological roots of anxious – or any other pathological – manifestations (e.g., Why do you think you have panic attacks?…”

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

“…In anxiety disorders, the importance of patients' capacity to reflect on anxiety symptoms and their relation to interpersonal events in particular has been demonstrated. This panic-focused reflective functioning has shown to be associated with the therapeutic alliance, in-session focus on interpersonal relationships and emotional expression, and outcome in both psychodynamic and cognitive-behavioral therapy (Keefe et al 2019, Solomonov et al 2019. More studies such as these focusing on disorder-specific impairments in mentalizing are needed, as they are consistent with research demonstrating the context-specific nature of mentalizing, and may have direct implications for improving therapeutic interventions across theoretical orientations.…”

Panic Disorder as Unthinkable Emotions: Alexithymia in Panic Disorder, a Croatian Cross-Sectional Study

“…Mentalization as capacity to understand ourselves and others could enhance alexithymic characteristics particularly items in DIF subscale which were negatively correlated with bias in emotion perception, especially in social relation (77). Exploration and interpretation of avoided emotions improve reflective function and mentalization in PD (78).…”