Background
Despite repeated treatments, many patients with dysthymia and panic disorder do not achieve remission or have persistent residual symptoms and functional impairments that pose a risk of relapse and recurrence [
1‐
3]. A general conclusion is that the effectiveness of existing treatments is limited with regard to long-term remission. Thus, a better understanding is needed of helpful treatment ingredients and hindering factors, as well as of the phenomenon of enduring remission.
Comorbidity, especially with personality disorders, has been shown to be a factor that renders remission more difficult for patients with dysthymic and panic disorders [
4,
5]. Both disorders are characterized by high frequencies of comorbid avoidant and obsessive-compulsive personality disorders [
6]. Concerning the influence of comorbid depression on the outcome of panic disorder the findings are somewhat inconsistent [
7,
8]. We suggest that a confounding factor may be insufficient differentiation between primary, early-onset dysthymia and secondary depressions. It is reasonable to assume that when panic disorder is successfully treated, secondary depressions may recede but that patients with primary dysthymic disorder may need other specific treatment ingredients. In order to explore factors for maintaining remission, we wanted to compare patients with dysthymia and patients with panic disorder without dysthymia.
Psychotherapy has long been promoted as providing enduring change. An important question, however, is how to understand the possible mechanisms involved in such a desirable outcome. Another long-standing issue is whether the benefits of psychotherapy derive from features common to all psychotherapies – such as the healing setting, psycho-education, and the therapeutic relationship – rather than to specific factors related to the type of therapy [
9]. A neglected circumstance is that the complex interactions between common and specific factors are associated with the character of a patient's problems. Bohart [
10] proposed an alternative model where patients' self-healing capacities are the common factor which makes therapy work. According to this model, patients take whatever techniques are provided and use them to obtain the needed changes. Moreover, they may have fairly elaborate perceptions of the obstacles to change. From the perspective of the patient as the expert on what works, patients' opinions about helpful and hindering factors for remission ought to promote the understanding of factors that affect outcome. Furthermore, an investigation of patients with dysthymia and panic disorder might show whether the perceived factors are similar or dissimilar.
In a comprehensive review, Elliott et al. [
11] summarised research on clients' experiences of psychotherapy under five helpful categories: (a) facilitative therapist characteristics, (b) client self-expression permitted, (c) experiencing supportive relationship, (d) client self-understanding, and (e) the therapist encouraging clients to practise new skills outside of therapy. To our knowledge, however, no studies have reported the perceptions of patients with a long duration of illness, trying to relate the findings to different diagnoses and degree of remission at long-term follow-up.
The purpose of the present study was to examine the phenomenon of remission by investigating the perceptions of patients with dysthymic and panic disorders with different long-term outcomes at 9-year follow-up. Specifically, we wanted to explore: (1) Perceived helpful and hindering factors, (2) Common and specific factors for the diagnostic groups, and (3) Convergence between patients' subjective views on remission with objective diagnostic assessments.
Results
Long-term outcome
At the follow-up, 26% (n = 6) of patients with dysthymia and 20% (n = 3) of patients with panic disorder were in remission according to SCID-I-interviews and symptom measures. According to the life-charting, they had been in remission between 1–8 years (median 4 years). Including partial remission individuals, 57% (n = 13) of patients with dysthymia and 47% (n = 7) of patients with panic disorder had improved. Both diagnostic groups had predominantly maladaptive traits in cluster C according to DSM-IV (mainly avoidant, obsessive-compulsive and dependent), (dysthymia 57%, n = 13, panic disorder 80%, n = 12), but traits in cluster A (mainly paranoid) and cluster B (mainly borderline) were also prevalent.
The subjective perceptions about life today, change and the future were generally convergent with diagnostic assessments according to DSM-IV definitions. General for remitted participants were perceptions of having received 'Tools to handle life', e.g.: "it is positive, now I have the requirements to handle my life", "the future is bright, as I have received the tools to push my life in the wanted direction."
Common factors
The analysis of the narrative data concerning perceived help and hindrance resulted in both common and specific categories for the diagnostic groups, as shown in Tables
2 and
3. The text describes variations between groups with different outcomes and diagnoses, illustrated with some short quotations and longer excerpts for central categories.
Table 2
Common categories of perceived helpful and hindering factors for remission based on a 9-year follow-up examination of 38 patients with panic disorder and dysthymia
Successful negotiations | Difficult negotiations |
- Fought for my request | - Misunderstood and rejected |
- Chose my therapist | - The patient is the underdog |
- Found financing for psychotherapy | - Problems financing psychotherapy |
- Enough time | - Too little time |
Antidepressant medications | Medication problems |
- Stabilizes | - Fear |
| - Side effects |
| - No problem solving |
Allowed to express myself | Therapist too non-directive |
Confidence in the therapist | Lack of confidence in the therapist |
Understanding myself and mechanisms | Lack of understanding |
Reasoning with myself | Reasoning with myself is not enough |
Important relations to others* | Unresolved relational problems* |
Table 3
Specific categories of perceived helpful and hindering factors for remission based on a 9-year follow-up examination of 38 patients with panic disorder and dysthymia
Therapist as coach | Phobias* | Therapist as parent | Mistrust of others* |
Relaxation techniques | Fear of anxiety* | Experiential and creative techniques | Sensitive to confirmation* |
Awareness and handling of feelings | Difficult handling bodily sensations and feelings* | Self-acceptance and compassion | Blaming self or others* |
Exposure gave confidence | | Feedback from others in group | Difficulties in close relations* |
| | Resolved relational problems | |
| | Several therapies important | |
The most common, almost general category was 'Difficult negotiations', defined as problems with access to treatment. Almost all participants described the process of receiving psychotherapy as a struggle about financing and time. Other hindering factors were perceptions of being misunderstood, rejected and powerless due to problems in expressing their needs forcefully enough. This was typical for those not in remission but also variant for others, especially early in the treatment history, e.g.: "I had no choice," "it's bad when they reject someone who is already an underdog," "she ruled by saying that there were no alternatives." In contrast, the category 'Successful negotiations,' defined as overcoming access problems, was typical for participants in full or partial remission. Faced with problems about the frames of treatment, they had fought and found solutions, e.g.: "I'm stubborn, I made contact again", "I know what I want and do not want," "the first therapist was odd, I wanted another one."
'Antidepressant medication stabilizes' was a typical common helpful factor, e.g.: "gave me stability," "made such a difference." However, 'Medication problems' was a typical hindering factor with complaints about physical and/or mental side effects resulting in dropout. Variant perceptions were that medication did not solve the basic problems or fear of medication. 'Confidence in the therapist' and 'Lack of confidence' were typical for both diagnostic groups. The only category that could be linked to a specific psychotherapy was 'Therapist too non-directive', associated with psychodynamic psychotherapy, e.g.; "therapist was silent, I didn't know what to say or do." 'Understanding myself and mechanisms' was the most common helpful factor, typical for all participants. For those in remission, it was a general category and described in terms of a tool to handle distress, e.g.: "it's just that I know what it is, that makes it possible for me to handle it" (original emphasis underlined). Understanding was linked to experiences in psychotherapy or reading books and magazines about mental health. 'Lack of understanding' was a variant hindering factor, which had made negotiations about treatments difficult.
'Reasoning with myself', defined as an enhanced ability to reflect on and modify own thoughts, was a typical helpful factor, irrespective of type of psychotherapy, e.g.: "I think that I have received the tools to reverse things, by being aware about how I think it is easier to reverse a depressed state." 'Important relations to others' (support from partner and friends, becoming a parent) was a typical and highly valued helpful factor irrespective of outcome. 'Unresolved relational problems' was a typical hindering factor for those in partial remission or non-remission, with predominance of participants with dysthymia.
Specific factors for panic disorder
Participants with panic disorder and dysthymia described specific helpful relationships to the therapist, irrespective of type of psychotherapy or outcome. In panic disorder it was typically described as good collaboration ('Therapist as coach'), e.g.: "like a coach," "educated me," "helped me reach my goals." 'Exposure gave confidence' and 'Relaxation techniques' were variant helpful factors. Relaxation was described as a help to control or tolerate sensations; the former by non-remitted participants, the latter described as follows by a participant in remission: "all this together gets you to relax and not to be so afraid of external impressions and to come to grips with your emotional turmoil." A general helpful factor for those in remission was 'Awareness and handling of feelings', illustrated by this excerpt:
"But first and foremost, for the first time in my life I have learnt to notice what I feel and, yes, reflect a little about how to handle it. So I have a
strategy
for times when it's difficult. I've never had that before, it used to become panic directly. Yes, I have received
tools
to hold on to in times of storm and thunder."
The enhanced capacity to identify, tolerate and handle feelings, especially anger, was perceived as a tool for "putting my foot down in a way I didn't do before," thereby reducing overload and stress. 'Difficult handling bodily sensations and feelings', 'Fear of anxiety' and 'Phobias' were typical hindering factors for those not in remission. Partial remission individuals had hindering persistent phobias.
Specific factors for dysthymia
In dysthymia, the relationship with the therapist was typically described as a caring relation ('Therapist as parent'), e.g.: "cared for me;" "secure;" "loving and accepting;" "made me feel liked;" "set limits." 'Experiential and creative techniques' and 'Feedback from others in group' were variant helpful factors, irrespective of outcome. General helpful factors for those in remission were 'Self-acceptance and compassion', 'Resolved relational problems' and 'Several therapies important'. The experience of a caring relationship with the therapist was an important factor in gaining a better self-acceptance for those in remission. The following quotation from a woman in remission from dysthymia illustrates this:
"Yes, it was just that I was met by opposition and received new perspectives on life or tools that, you had not those blinkers against positive things, so instead I have started to be able to receive
good
things that others do for me too and grow with that. I grew through the support I received ...()...Yes, I think that I have received loving care, without those demands my parents had on me, and I have been allowed to grow through communication."
The hindering factors 'Mistrust of others' and 'Blaming self and others' were typical for individuals in partial and non-remission. 'Difficulties in close relations' was a general factor, and 'Sensitive to confirmation' was a typical factor for non-remission.
Conclusion
Based on the findings from this study and other research, we propose a general model for enduring remission from dysthymic and panic disorders that involves functional changes, i.e. (1) understanding self and illness mechanisms, (2) enhanced flexibility of thinking, and (3) change from avoidance to approach coping. A necessary vehicle for this change is a helpful relationship with the therapist and the clinician. In addition, differentiation between early-onset dysthymia and secondary depression is essential since patients with dysthymia and panic disorder seem to need change in specific areas. Concerning panic patients, clinicians need to recognise that elements of treatment can function as safety seeking behaviours. A key target in the treatment of patients with panic disorder with agoraphobia might be training of emotional awareness, tolerance and management. In treatment of patients with early-onset dysthymia, the need for an alliance factor of personal attachment to gain self-acceptance will be further investigated. Moreover, this study indicates that patients with personality disorders have difficulty in negotiating treatments, which may be a factor that contributes to a persistent course. We will deepen the investigation on this matter as participants perceived access problems to be the most hindering factor for remission.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CS designed the study, carried out the data collection, analyzed the data, and drafted the manuscript. SB analysed the qualitative data and assisted in writing the paper. AW conceived the study, participated in its design and coordination and helped to draft the manuscript. KL supervised the qualitative aspects of the study, was an auditor of the qualitative analysis and assisted in writing the paper. All authors read and approved the final manuscript.