Treatment of panic disorder

Panic disorder with or without agoraphobia occurs commonly in patients in primary care settings. This article assesses multiple evidence-based reviews of effective treatments for panic disorder. Antidepressant medications successfully reduce the severity of panic symptoms and eliminate panic attacks. Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective in the treatment of panic disorder. The choice of medication is based on side effect profiles and patient preferences. Strong evidence supports the effectiveness of cognitive behavior therapy in treating panic disorder. Family physicians who are not trained in cognitive behavior therapy may refer patients with panic disorder to therapists with such training. Cognitive behavior therapy can be used alone or in combination with antidepressants to treat patients with panic disorder. Benzodiazepines are effective in treating panic disorder symptoms, but they are less effective than antidepressants and cognitive behavior therapy.     

Self-Understanding, Empathy, Guided Discovery, and Schema Belief in Schema-Focused Cognitive Therapy of Personality Problems: A Process–Outcome Study

The aim of this study was to examine the dispositional and/or episodic influences of the process variables of self-understanding, empathy, guided discovery, and convictions about primary early maladaptive schema, which are central concepts in the schema-focused cognitive therapy of personality problems. The sample consisted of 35 patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits who participated in an 11-week inpatient program. Patients, therapists, and an expert observer rated individual therapy sessions. Greater patient-rated self-understanding the first session was related to greater decreases in schema belief and of emotional distress throughout therapy. Greater therapist-rated empathic experience the first session was related to greater decreases in distress throughout therapy. Session-by-session analyses revealed few sequential relationships. However, a greater in-session reduction of schema belief weakly predicted lower level of presessional distress the next session, and vice versa. The study illustrates how to intensively measure and model change in psychotherapy, using both growth curve and time series analyses.     

Clinical effect and tolerance of paxil (paroxetine) in management of panic disorders

AIM: To determine clinical efficiency and tolerance of paxil (paroxetin) in the treatment of panic disorders. MATERIAL AND METHODS: An open, non-comparative 7 week study entered 60 patients (mean age 36.6 +/- 3.22 years) with panic disorders and agoraphobias with panic disorders. Paroxetin was given in a single daily dose 20-60 mg/day in the morning. The results were assessed by Hamilton and Sihan scales, scale of clinical impression, by reduction of panic attacks. RESULTS: In 72.2% of patients panic attacks ceased or occurred less frequently (by 50%). Anxiety relieved by 67 +/- 4.6%. The number of the responders was greater while the effect occurred faster in patients with panic disorders. The drug was well tolerated, side effects occurred in 43.3% of cases. They were mild or moderate. CONCLUSION: Paroxetin has a prominent anxiolytic and antiphobic action, is well tolerated and is effective in panic disorders and agoraphobia with panic disorders.     

Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: randomized controlled trial with pre-registration nursing students

BACKGROUND: Exposure therapy is effective for phobic anxiety disorders (specific phobias, agoraphobia, social phobia) and panic disorder. Despite their high prevalence in the community, sufferers often get no treatment or if they do, it is usually after a long delay. This is largely due to the scarcity of healthcare professionals trained in exposure therapy, which is due, in part, to the high cost of training. Traditional teaching methods employed are labour intensive, being based mainly on role-play in small groups with feedback and coaching from experienced trainers. In an attempt to increase knowledge and skills in exposure therapy, there is now some interest in providing relevant teaching as part of pre-registration nurse education. Computers have been developed to teach terminology and simulate clinical scenarios for health professionals, and offer a potentially cost effective alternative to traditional teaching methods. OBJECTIVE: To test whether student nurses would learn about exposure therapy for phobia/panic as well by computer-aided self-instruction as by face-to-face teaching, and to compare the individual and combined effects of two educational methods, traditional face-to-face teaching comprising a presentation with discussion and questions/answers by a specialist cognitive behaviour nurse therapist, and a computer-aided self-instructional programme based on a self-help programme for patients with phobia/panic called FearFighter, on students' knowledge, skills and satisfaction. DESIGN: Randomised controlled trial, with a crossover, completed in 2 consecutive days over a period of 4h per day. PARTICIPANTS: Ninety-two mental health pre-registration nursing students, of mixed gender, age and ethnic origin, with no previous training in cognitive behaviour therapy studying at one UK university. RESULTS: The two teaching methods led to similar improvements in knowledge and skills, and to similar satisfaction, when used alone. Using them in tandem conferred no added benefit. Computer-aided self-instruction was more efficient as it saved teacher preparation and delivery time, and needed no specialist tutor. CONCLUSION: Computer-aided self-instruction saved almost all preparation time and delivery effort for the expert teacher. When added to past results in medical students, the present results in nurses justify the use of computer-aided self-instruction for learning about exposure therapy and phobia/panic and of research into its value for other areas of health education.     

Gender Differences in Patients with Panic Disorder: Evaluating Cognitive Mediation of Phobic Avoidance

Epidemiologic reports have consistently found that females are at greater risk for the development of panic disorder, in particular, when it is accompanied by agoraphobia. Although gender appears to be a well-established risk factor for the development of phobic avoidance, the mechanisms that account for this increased risk have yet to be delineated. Often, gender differences in phobic avoidance are speculated to arise from differences in courage (e.g., men are expected to be brave and endure fear-provoking situations). Our study evaluated this popular but unsubstantiated theory and advanced another hypothesis: Differences in panic- and arousal-related cognitions may account for gender differences in phobic avoidance. Male (n = 27) and female (n = 61) patients meeting DSM-IV criteria for panic disorder with or without agoraphobia were evaluated. Data did not support gender differences in courage; nor were these indices related to phobic avoidance. In contrast, there were significant gender differences in several cognitive domains. Moreover, anxiety sensitivity and panic-related appraisals mediated gender differences in phobic avoidance.     

Panic disorder and agoraphobia. Nondrug treatment options for primary care physicians

Panic disorder, including agoraphobia, is a common psychiatric illness that can be successfully treated by primary care physicians. Although medication for this disorder is available, many investigators advocate behavior therapy or other nonpharmacologic treatment initially. Patients can learn techniques to control the anxiety they feel about having an attack and to deal with issues in their life that may cause panic. Referral to a psychiatrist may be indicated for patients with resistant or complex cases.     

A pilot open trial of brief psychodynamic psychotherapy for panic disorder.

This is a complete report of an open trial of manualized psychodynamic psychotherapy for treatment of panic disorder, Panic-Focused Psychodynamic Psychotherapy (PFPP). Twenty-one patients with PD were entered into a trial of twice-weekly, 24-session treatment. Sixteen of 21 experienced remission of panic and agoraphobia. Treatment completers with depression also experienced remission of depression. Improvements in symptoms and in quality of life were substantial and consistent across all measured areas. Symptomatic gains were maintained over 6 months. This report was prepared specifically to describe 6-month follow-up on these patients. Psychodynamic psychotherapy appears to be a promising nonpharmacological treatment for panic disorder.     

Agoraphobia. Is fear the basis of symptoms?

All human beings are biologic, psychological, and sociologic creatures. The treatment program for agoraphobia at the University of Kansas Medical Center School of Medicine, Kansas City, is designed to deal effectively with problems in these three areas. The biologic area is dealt with by medication; tricyclic antidepressants are used to block panic attacks, and benzodiazepines are given, as needed, for anticipatory anxiety. Group therapy is particularly effective in the areas of individual psychopathology and social anxiety. We have not found agoraphobia difficult to treat and have demonstrated that it can be cured. The track record of primary care physicians and specialists in diagnosing and managing agoraphobia so far leaves much to be desired. If physicians obtain the appropriate history at initial contact with a patient and administer appropriate treatment, it may be possible to prevent full-blown agoraphobia from developing.     

Panic Control Treatment and Its Applications

Panic Control Treatment (PCT) is a widely used, empirically validated cognitive-behavioral treatment for panic disorder. Initially developed for the treatment of panic disorder with limited agoraphobic avoidance, PCT more recently has been finding broader applications. It has been used as an aid to pharmacotherapy discontinuation in panic disorder; in the treatment of panic attacks associated with other disorders such as schizophrenia; and, in combination with a situational exposure component, in the treatment of patients with moderate to severe agoraphobia. The authors critically review the evidence for the clinical efficacy of PCT and recent work directed at further enhancing the long-term efficacy and cost-effectiveness of treatment. (The Journal of Psychotherapy Practice and Research 1999; 8:3–11)Since panic disorder was formally recognized as a discrete entity in DSM-III, it has become one of the most intensively studied anxiety disorders. By definition, panic disorder causes significant distress or interference with the individual''s life, exacting substantial personal costs. In addition, the disorder imposes high direct and indirect costs on the nation in medical resources used for care, treatment, and rehabilitation and in reduced or lost productivity.¹A growing body of evidence supports both the efficacy and effectiveness (clinical utility) of psychosocial interventions for panic disorder. For example, a recent meta-analysis of 43 controlled studies found that cognitive and cognitive-behavioral treatments, collectively, had a higher mean treatment effect size and a lower attrition rate than pharmacological treatments.² In addition, evidence is beginning to appear from naturalistic studies that cognitive-behavioral therapy for panic disorder may be more cost-effective than pharmacotherapy, even within the first treatment year.³Yet despite the demonstrated efficacy and favorable cost profile of cognitive-behavioral therapy for panic disorder,⁴ most patients treated in clinical practice settings do not receive it.^5–7 That situation is due in large part to two problems: limited knowledge by physicians and the general public about the nature and benefits of cognitive-behavioral therapies, and the lack of an effective means for disseminating new treatments, resulting in reduced treatment availability.⁸ The present article provides an overview of one of the most well-studied forms of cognitive-behavioral therapy for panic disorder, Panic Control Treatment (PCT),^9,10 and reviews the evidence for its efficacy. Also reviewed is some recent work directed at extending the application of PCT to new populations and enhancing its long-term efficacy and cost-effectiveness.     

Benzodiazepine Use Associated with Decreased Memory for Psychoeducation Material in Cognitive Behavioral Therapy for Panic Disorder

In laboratory studies with nonanxious participants, benzodiazepines (BZ) reliably induce anterograde amnesia. It remains unclear whether memory impairments exist for information presented in therapy among anxiety patients who are concomitantly taking BZs. This naturalistic study compared 16 panic disorder patients who were daily BZ users with 16 age- and education-matched, nonmedicated panic disorder patients. An incidental memory task assessed memory for psychoeducation material on the origins and management of somatic anxiety symptoms presented during group cognitive behavioral therapy (CBT). BZ users showed significantly poorer memory performance than controls although there were no group differences in anxiety symptoms, rates of psychiatric comorbidity, or sedation. Among BZ users, a higher number of minutes away from post peak drug-blood concentration when encoding began, was also associated with better incidental memory performance. Although causation cannot be inferred from this naturalistic study, the memory impairments observed among BZ users may contribute to the poorer efficacy of CBT previously documented in panic disorder patients receiving adjunctive BZs.     

Panic disorder

Panic disorder affects an estimated 1.4 percent of the general population. Nearly 70 percent of patients with panic disorder may also suffer from a major depressive disorder at some time in their lives. Both disorders respond to tricyclic antidepressants and monoamine oxidase inhibitors. Alprazolam is also an effective antipanic agent. Because avoidance behaviour (agoraphobia) often follows the onset of panic disorder, behavioral interventions are an important adjunct to management.     

New ways of treating panic disorder

The research evidence strongly suggests that the most effective form of treatment for panic disorder is cognitive therapy. It is more practical, however, to initiate treatment with alprazolam or with imipramine. Either drug will suppress symptoms and even a half of the patients will stay well.     

Do Changes in Panic Appraisal Predict Improvement in Clinical Status Following Cognitive-Behavioral Treatment of Panic Disorder?

The effects of changes in panic appraisal dimensions during cognitive-behavioral treatment (CBT) on both short- and long-term improvement in panic disorder symptoms were examined. Panic disorder severity and panic appraisal measures were collected from 120 CBT-treated patients at pretreatment, post-treatment, and 6-month follow-up. Several panic appraisal dimensions investigated in panic disorder and agoraphobia include (a) perceived likelihood of panic occurrence (i.e., anticipated panic), (b) perceived negative consequences of panic occurrence, and (c) perceived panic coping efficacy. Of those panic appraisal dimensions studied, change in anticipated panic during treatment emerged as the most potent predictor of short-term improvement across each of the major clinical status measures (i.e., panic attack frequency, agoraphobic avoidance, and anxiety). Change in perceived consequences of panic uniquely contributed to short-term improvement in both anxiety and global disability, and reduction in perceived panic coping efficacy was unique predictor of short-term improvement in only agoraphobic avoidance. Both changes in perceived consequences of panic and in anticipated panic uniquely contributed to long-term improvement in agoraphobic avoidance and anxiety, respectively. In addition, only change in perceived consequences of panic uniquely contributed to long-term improvement in global disability. In contrast, perceived panic coping efficacy was generally a weak predictor of long-term improvement in any measures of clinical status. These results suggest that changes in cognitive appraisal factors predict both short- and long-term improvement during CBT of panic disorder.

Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy

Psychological factors such as stress and depression have already been established as primary and secondary cardiovascular risk factors. More recently, the role of anxiety in increasing cardiac risk has also been studied. The underlying mechanisms of increased cardiac risk in panic disorder patients seem to reflect the direct and indirect effects of autonomic dysfunction, as well as behavioral risk factors associated with an unhealthy lifestyle. Implications of the comorbidity between panic and cardiovascular disease include higher morbidity, functional deficits, increased cardiovascular risk, and poor adherence to cardiac rehabilitation or exercise programs. This article probes the most recent evidence on the association between coronary artery disease, anxiety and panic disorder, and discusses the potential role of incorporating regular physical exercise and cognitive behavioral therapy in the treatment of this condition.     

Tests of the generality of self-efficacy theory

The present set of studies tested the explanatory and predictive generality of self-efficacy theory across additional treatment modalities and behavioral domains. Microanalysis of changes accompanying symbolic modeling indicates that this mode of treatment enhances coping behavior partly through its effects on perceived efficacy. Cognizing modeled mastery of threats increased phobics' self-percepts of efficacy, which, in turn, predicted their specific performance attainments on tasks of varying threat value. Examination of efficacy probes revealed that making efficacy judgments has no effect on subsequent avoidance behavior or on fear arousal. The close congruence found between changes in self-efficacy and different forms of coping behavior in the treatment of agoraphobia provides some evidence for the generality of efficacy theory across different areas of functioning. Microanalysis of anticipatory and performance fear arousal accompanying varying strengths of self-efficacy also lends support for the social learning conception of fear arousal in terms of perceived coping inefficacy.This research was supported by Public Health Research Grant M-5162 from the National Institute of Mental Health. The authors are grateful to Seanna Adamson for administering the assessment procedures and to Evelyn Nast for her able assistance with the cognitive modeling treatment. We are deeply indebted to Sue Lampson for her valuable aid with the assessment phase of the agoraphobia study and to the staff of the Terrap treatment center for their generous help with this research.     

Emerging from depression and panic disorder into a normal life: a case report

This study documents the nursing experience of caring for a patient with depression and panic disorder, using cognitive therapy. The subject had experienced chronic depression and repeated panic attacks for an extended period of time, which had a negative impact on both her and her family. In addition to applying relaxation techniques to alleviate discomfort resulting from repeated hyperventilation, the author also noted that negative emotion was the common cause of the subject's depression and anxiety. Such patients habitually experience negative cognition, which influences their emotions and behaviors. Plans were therefore developed to assist the subject in: (i) recognizing her negative automatic thoughts, (ii) realizing that her physical discomfort and lack of problem-solving skills were both related to such thoughts, and (iii) correcting cognitive distortion by substituting negative automatic thoughts with positive thoughts. Upon implementation of these plans, distinctly lessened depression and anxiety, and distinctly improved coping abilities were all noted. With panic attacks diminishing and individual coping abilities improved, a normal social life was again on the horizon for the subject. It is hoped that this study will be of use as a source of reference in the care of similar cases in the future.     

Managing panic attacks in emergency patients

Patients experiencing panic attacks often seek help at emergency departments. However, the symptoms of panic can be difficult to distinguish from some common medical emergencies. Furthermore, many emergency medicine clinicians may not be equipped to deal effectively with panic attacks and related psychiatric conditions such as panic disorder and agoraphobia. Early misdiagnosis and inadequate management of panic attacks can have devastating long-term clinical and financial consequences. The purpose of this paper is to provide information designed to increase the comfort and efficacy of emergency physicians and allied professionals in dealing with panic attacks. The authors offer guidelines regarding differential diagnosis, present strategies for management of acute symptoms of panic and anxiety, and make recommendations for brief postpanic clinical intervention.     

The Contribution of Anxiety Sensitivity to Obsessive–Compulsive and Anxiety Symptoms in a Naturalistic Treatment Setting

Anxiety sensitivity (AS), a fear of arousal-related sensations, is prevalent in a number of disorders. We examined the relationship between internalizing symptoms and the anxiety sensitivity components of physical, social, and cognitive concerns in a sample of 165 patients seeking treatment in a clinic specializing in cognitive behavioral therapy for anxiety-related disorders. Social anxiety symptoms were associated with greater social concerns. Cognitive concerns were characteristic of both depression and generalized anxiety symptoms, suggesting these two classes of symptoms may share AS symptomatology. Physical concerns were specifically related to panic symptoms. Although obsessive–compulsive symptoms were related to cognitive concerns using univariate regression, these symptoms were not strongly related to any of the anxiety sensitivity components when the correlation between disorders was taken into account. Thus, within the internalizing symptoms studied here, the anxiety sensitivity domains were most relevant to panic, social anxiety, generalized anxiety, and depressive symptoms and less related to obsessive–compulsive symptoms.     

Fear of fear and the anxiety disorders

The responses of 271 outpatients with diagnoses of agoraphobia with panic attacks, panic disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, or depression (major depressive disorder or dysthymic disorder) to the Agoraphobic Cognitions Questionnaire (ACQ) and the Body Sensations Questionnaire (BSQ) were examined. Agoraphobics scored significantly higher than all other groups on fear of body sensations associated with anxiety. In addition, agoraphobics, together with clients with panic disorder, had significantly higher scores on thoughts that physical illness would be caused by their anxiety. All clinical groups scored significantly higher than normal controls on thoughts that their anxiety would lead to social embarrassment or loss of control; there were no significant differences among clinical subjects on this measure, although agoraphobics' scores were higher than those of all other groups. In addition, analyses of data from 364 agoraphobics showed that the ACQ and BSQ predicted an important feature of agoraphobia—namely, self-reported avoidance behavior, even once the common variance of fear of fear with trait anxiety was partialed out. In summary, it appears that fear of fear is an important distinguishing characteristic among clients with anxiety disorders, and one that cannot be reduced to global psychological distress or trait anxiety.The authors wish to thank Aaron T. Beck, Gary Brown, and Gail Steketee, whose cooperation in data collection made this study possible; Nazareth Pantaloni, for his assistance in data analysis; and Carol Glass, for her helpful comments on an earlier draft of this paper.