Psychotherapy based on depth psychology at Anxiety Disorders

The S3 guideline on the treatment of anxiety disorders ranks cognitive behavioral therapy (CBT) as the first-line treatment for both panic disorder and generalized anxiety disorder. Psychodynamic therapy follows, with a lower level of recommendation.

Generalized anxiety disorder and panic disorder—with or without agoraphobia—are the two conditions about which the guideline provides the most information regarding psychodynamic therapy. Social phobia receives the same conditional recommendation, with a level of evidence of Ib.

It should be offered, but only under three conditions. For panic disorder and agoraphobia, the guideline states verbatim in Recommendation 8: „Patients with panic disorder/agoraphobia should be offered psychodynamic psychotherapy if CBT has not proven effective, is not available, or if the informed patient expresses a preference for it.“

These three conditions constitute the actual substance of these two recommendations. Psychodynamic therapy comes into play when CBT has not been effective, when it is not available, or when an informed patient prefers it. All three approaches lead to the same treatment option.

For both panic disorder and generalized anxiety disorder, CBT has a level of evidence of Ia and a recommendation grade of A+, formulated as „should.“ Psychodynamic therapy has a level of evidence of IIa and a recommendation grade of B+, formulated as „should.“ One level lower, one condition longer.

The professional associations for depth psychology and psychoanalysis contributed to this consensus: It is their own assessment.

The lower ranking is based on individual studies graded according to quality deficiencies. According to the guideline, IIa means: „Evidence from at least one methodologically well-controlled study without randomization.“ B+ means: „‚Should‘ recommendation: Well-conducted clinical studies, but no randomized clinical trials, with direct relevance to the recommendation (evidence levels II or III) or extrapolation from evidence level I if there is no direct relevance to the specific research question.“

That sounds like a contradiction, because there are randomized studies on psychodynamic therapy for panic disorder. Milrod 2007 is one of them. Nevertheless, the guideline downgrades it and explains why: „Due to methodological flaws identified here, the level of evidence was downgraded (e.g., from Ib to IIb for an RCT with moderate flaws; to IV for those with serious flaws).“

The guideline illustrates how this applies in specific cases by referencing a study that was conducted simultaneously at two sites. It abbreviates psychodynamic therapy as PDTh and provides a separate statement for each site. Regarding the CORNELL site, it states that the study „shows no superiority of PDTh over the control group; nor can it be used as evidence of the equal efficacy of CBT and PDTh.“ Regarding the PENN site, it states that the study „shows that PDTh is inferior to CBT and even to the control group.“ The same study, the same methodology, two different results. It is precisely such findings that lower the level of evidence.

The Cochrane Network on Psychotherapies for Panic Disorder provides the clearest explanation. It reviews 54 studies involving 3,021 patients. For the most important outcome—the remission of symptoms after a short period of time—there were 32 studies on CBT compared to only two studies on psychodynamic therapy. The quality of evidence was consistently low across the entire network. Two studies versus thirty-two do not indicate equivalence. However, they also do not indicate inferiority.

The authors also note that psychodynamic therapy showed promising results in the two available studies, that it was the best tolerated of all the psychotherapies examined, as measured by dropout rates, and that, in the long term, CBT and psychodynamic therapy showed the highest remission and response rates. They note that all of these differences are small or imprecise. What is lacking are studies.

There is a counterargument, and it is worth considering. In 2014, Keefe and colleagues reviewed fourteen randomized studies involving 1,073 patients and found psychodynamic therapy to be just as effective as other treatments for anxiety disorders. Nevertheless, the guideline excludes this meta-analysis from its assessment, stating that it did not meet the guideline’s criteria, nor did the majority of the individual studies included in it.

However, since the guideline development group reviewed the literature, two network meta-analyses have been published that examine precisely these two clinical conditions separately. These were not yet available to the guideline development group, and they alter the picture in two ways.

In a 2022 article in the *British Journal of Psychiatry*, Papola and colleagues analyzed 136 randomized trials on panic disorder with and without agoraphobia. Compared to usual care, two approaches performed best: CBT and short-term psychodynamic therapy. Confidence in the findings was unevenly distributed—moderate for CBT and low for psychodynamic therapy—and after excluding studies with a high risk of bias, only CBT remained superior to standard care. Nevertheless, the authors concluded that both are acceptable first-line treatments.

In 2024, Papola and colleagues analyzed 65 randomized trials involving 5,048 participants regarding generalized anxiety disorder in *JAMA Psychiatry*. Psychodynamic therapy was one of the eight approaches examined. In that analysis, CBT, third-wave approaches, and relaxation therapy were found to be superior to standard care; psychodynamic therapy was not among them. Three to twelve months after the end of treatment, only CBT continued to show a benefit. However, the study found no demonstrable difference in efficacy among the various psychotherapy approaches.

All in all, this means that for generalized anxiety disorder, CBT is the most well-supported treatment option—even more so than the 2021 guidelines indicate. For panic disorder, on the other hand, psychodynamic brief therapy is rated more highly in recent studies than in the German guidelines.

Behavior can be measured, but an unconscious conflict cannot.

How often someone avoids a situation, how high the panic level is on a scale of zero to ten, how many fewer points a questionnaire shows after eight weeks: All of this ends up in a table and can be compared between two groups. There is no similarly convenient scale for transference, defense mechanisms, or the maturation of a personality structure. Research follows what can be demonstrated.

In a 2010 article in *American Psychologist*, Jonathan Shedler quantified the gap: There are possibly ten times as many randomized studies on CBT as on psychodynamic approaches. He attributes part of this to the analysts themselves, because earlier generations considered empirical research unnecessary. The lead held by cognitive approaches dates back decades.

Then there is the issue of treatment duration. Shedler describes comparisons in which psychodynamic treatments consisting of eight sessions were pitted against CBT consisting of sixteen sessions. Even in those cases, the results were comparable. The studies underlying the two recommendations in this guideline are of a similar magnitude, with up to 24 hours for panic disorder and up to 30 hours for generalized anxiety disorder.

And the bar is set high. What these studies measure is the level of symptoms: scores on an anxiety questionnaire, panic attacks per week. Whether someone is subsequently better able to take care of themselves, tolerate closeness, or express anger does not show up in these numbers. Shedler calls this the gap between what psychodynamic treatment aims to achieve and what is ultimately measured.

A third point concerns the patients themselves. In 2004, Drew Westen and his colleagues showed that psychotherapy studies often exclude up to two-thirds of applicants, mostly because they have more than one mental health issue. It is precisely these people who are sitting in the therapist’s office.

In my experience, the first thirty hours of therapy for generalized anxiety disorder are spent getting to know one another. More than that happens during this time. However, working through the same pattern over and over again—in ever-changing contexts—and the subsequent maturation of the personality structure that goes along with it require the time that follows. That is precisely where the research literature ends.

The decision rule is already stated above, but it is rarely recognized as such. The three conditions from Recommendations 8 and 23—CBT is not effective, CBT is not available, or patient preference—are the answer to the question of when which treatment is appropriate.

In practice, the two approaches differ in their focus. According to the guidelines, modern behavioral therapy incorporates cognitive, behavior-modifying, emotion-enhancing, and confrontational elements. The cognitive behavioral therapy assumes that significant life events leave behind fixed patterns of thought that later influence how a situation is assessed and what emotion follows; a key component is confronting what triggers fear. Depth psychology focuses more on the unconscious conflict, from which the symptom arose, and the relationship patterns that underlie it.

Both have a model of how an anxiety disorder develops and what sustains it, and both take different therapeutic approaches. Those who view anxiety primarily as a signal of an unresolved inner conflict will want to work on that conflict. Those who view it primarily through the lens of the evaluations and avoidance behaviors that keep it alive will focus their efforts there. Both perspectives describe real aspects of the same disorder.

Based on the current data, it is not possible to definitively determine which method is generally superior.

Depth psychology first asks where the anxiety comes from. It distinguishes between two sources: unconscious conflicts and structure. This distinction determines the course of treatment.

Fear of Conflict: A Sign of Unconscious Conflicts

One source is conflict. A desire or impulse contradicts an inner prohibition, and fear signals this contradiction before it becomes conscious. Because this fear signals something, we also refer to its signaling function. It is directed: it can be tied to specific situations, specific relationships, or recurring triggers. Most people can name exactly what they’re afraid of, even if the situation appears harmless from the outside.

A vague sense of anxiety when the bond doesn't form

The other source is the structure. Diffuse anxiety has no identifiable object. It lacks direction because the ability to anchor anxiety to something is absent. This anchoring of anxiety is considered a sign of ego strength: it serves as a warning when it succeeds. If it fails, anxiety overwhelms the individual. From this perspective, a phobia is an achievement: diffuse anxiety has attached itself to an object and has thus become more bearable.

There is a broad spectrum between the two, and the boundaries are fluid. Ermann classifies fears of feeling helpless and at the mercy of others—as in agoraphobia—or fears about one’s own body as falling in the middle between these two extremes.

Depth psychology therapy employs two different approaches for these two sources: one insight-oriented and one experience-oriented. In the case of conflict-related anxiety, the focus is on insight: the conflict from which the anxiety arose is understood and addressed. With diffuse anxiety, however, this very process of uncovering the root cause would be the wrong approach. Here, the initial focus is on experience and skills: perceiving, naming, enduring, and being able to calm oneself.

Which of the two sources takes precedence is therefore clarified at the beginning of treatment. Because the boundaries between them are fluid, the question remains open for adjustment throughout the entire course of treatment.

Honesty is key. The studies on which these two recommendations are based lasted up to 24 hours for panic disorder and up to 30 hours for generalized anxiety disorder. The psychotherapy guidelines initially specify short-term therapy for adults: two sessions of up to 12 hours each, for a total of 24 hours. The studies on panic disorder fall precisely within this framework. In addition, the guideline provides for approval steps up to 60 hours and a maximum limit of 100 hours for this approach in an individual setting. The guideline itself points out this gap, using the example of the even longer analytical approach: „Although reimbursement by insurance providers for analytical therapies can reach up to 300 hours under guideline procedures in Germany, there is no evidence for this in clinical studies.” What can be reimbursed thus goes well beyond what was tested in the underlying studies. An unproven effect is not the same as a disproved one: controlled evidence is lacking for this extended timeframe. Just as the same distinction applies to a Depression I've described what it looks like elsewhere.

I have never referred anyone with an anxiety disorder to behavioral therapy. The focus has always been on understanding the anxiety.

I have a basic understanding of behavioral therapy, and I myself have sometimes encouraged behavioral experiments to confront anxiety.