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. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trial registration: ClinicalTrials.gov NCT00353470.

Figure 1.

Estimated effect sizes for the relationship between the average level of emotion expression across sessions 2, 5, and 10, and subsequent improvement in panic symptoms as measured by the PDSS. Positive semipartial correlations indicate that higher levels of expression are associated with more subsequent symptom improvement. Bars are 95% confidence intervals.

Figure 2.

Estimated change in panic symptoms as measured by the PDSS between Weeks 5 to Termination (Week 12), as a function of the average overall emotional expression between sessions 2, 5, and 10, and their interaction with the number of SCID-II borderline personality disorder criteria a patient met at baseline. Increasingly negative values represent greater predicted symptom improvement. All regression variables not displayed in the figure were set to the sample means.