Article
| Disorder | Psychodynamic Theory | Psychodynamic Treatment Approach |
|---|---|---|
| Panic Disorder | Those vulnerable to panic onset have a fearful dependency on others. Anger and autonomy feel threatening to these insecure attachment relationships. Panic displaces these fears in part to the body and provides a means to seek attachment and deny any threat from anger (“I’m helpless and sick. I need you. I’m not a danger”). | Focus on the context and feelings surrounding panic episodes to help identify meanings of symptoms. Identify core dynamics: fear of disruption of close relationships, threats from angry feelings, and defenses against anger and separation fears (undoing, reaction formation, denial). Address problems in interpersonal relationships, including fears of assertion and frustration with unresponsive others. |
| Agoraphobia | Agoraphobic symptoms are attempts—typically unconscious—to manage conflicts surrounding anger, autonomy, and separation, as well as fears of lack of control. Internal conflicts are externalized to dangers in the environment. Patients’ fears add to dependency on others and reduce the perceived threat from anger; anger may be expressed indirectly in a coercive effort to control others. | Clarify the content of patients’ symptoms to identify and address underlying aggression and separation fears, including in the transference. Explore why patients may avoid exposing themselves to fearful situations as they gain an understanding of symptoms (but there is no formal exposure). |
| Social Anxiety Disorder | Underlying feelings of inadequacy and fears of rejection by others can trigger compensatory grandiose fantasies. Conflicted wishes to exhibit oneself and outshine others are associated with unacceptable aggression, triggering guilt and self-punishment. | Identify the context, fantasies, and emotions surrounding experiences of social anxiety. Explore and address feelings of inadequacy, conflicted aggression, and guilt-ridden grandiose and exhibitionistic fantasies. Identify these dynamics as they emerge in patients’ overly critical view of themselves and expectation of others’ negative judgment. |
| Generalized Anxiety Disorder (GAD) | Fears of usually unconscious conflicted feelings and fantasies becoming out of control create the need to maintain constant vigilance, with worries displaced to the body or other areas of patients’ lives (e.g., finances, external environment). | Identify conflicts regarding aggressive, sexual, and dependent wishes, which patients fear will be out of control. Recognize the role of hypervigilance as an effort to manage these wishes. Identify how fears of the external environment or the body are displaced from intrapsychic fears. |
| Post-Traumatic Stress Disorder (PTSD) | Overwhelming trauma triggers dissociation, rage, fear of loss, and unconscious repetition of trauma. Rage at perpetrators can lead to identification with the aggressor, which triggers intense guilt. | Identify the function, meaning, and impact of dissociation. Explore conflicted feelings brought on by trauma that fuel dissociation and other symptoms. Identify sources of guilt that trigger self-punishment, such as identification with the aggressor and survivor guilt. Focus on factors, such as an effort to control trauma, that lead to reenactments. |
| Cluster C Personality Disorders (Avoidant, Dependent, Obsessive-Compulsive) | Conflicts about aggression and dependency wishes fuel chronic passivity, avoidance, inhibition of autonomy, and angry feelings characteristic of these disorders. | Identify and address conflicted aggression to detoxify it, leading to improved ability to assert oneself, increased autonomous function, and less need of support from others. Interpret passivity, aggression, and dependency in the transference to facilitate these shifts. |
| Major Depression | Narcissistic vulnerability (sensitivity to rejection) fuels conflicted aggression, as well as compensatory high self-expectations and idealization of others, triggering recurrent disappointment. Conflicted aggression leads to guilt, self-criticism, and depressive symptoms. | Identify and address conflicted aggression to detoxify it, easing guilt. Provide recognition of overly high expectations of self and others to help avert disappointment, anger, and low self-esteem. |
| Borderline Personality Disorder | Inability to modulate and tolerate negative affects, such as rage or envy, leads to fears of destroying a needed “good” other (Kernberg 1967). A split perception of others as “all good” or “all bad” defensively focuses rage on the devalued bad other, protecting idealized attachment figures. Splitting interferes with the development of more complex views of self and others and a more consolidated identity, adding to dysregulation of negative emotions. Disruptions in mentalization capacities interfere with patients’ ability to accurately identify motives and emotions in self and others. | Address intense rageful feelings and fantasies, along with split and shifting self and other representations as they emerge with the therapist, to help clarify and manage the intolerable feelings and defensive splitting (Yeomans et al. 2015). Work to develop patients’ mentalization capacities (Bateman and Fonagy 2016). |
| Narcissistic Personality Disorder | Patients’ underlying low self-esteem, often suppressed, triggers compensatory idealized views of themselves and others who recognize their specialness. These idealized expectations lead to recurrent disappointment with others’ actual responses. A reactive rage and devaluation of others who criticize them or do not recognize their specialness develop. Frequent anger, disappointment, and limited empathy toward others disrupt close relationships. | Explore the circumstances in which patients feel disappointed and enraged at others for not adequately recognizing their capabilities or responding to their demands. Identify feelings of inadequacy and efforts to manage self-esteem through idealized self-views and expectations of others. Inevitable disappointment and rage at the therapist provides the opportunity to identify and ameliorate these dynamics in the transference.Busch, F. N. (2021). Problem-focused psychodynamic psychotherapies. Psychiatric Services, 72(12), 1461-1463. |
