Panic disorder cognitive-behavioral

As with panic disorder, cognitive-behavioral therapy is an important part of the treatment program for social anxiety disorder. Some evidence suggests that in some cases, drug treatment did not improve the effects of receiving cognitive-behavior therapy. 

In two studies in which benzodia2epines were gradually tapered, concurrent cognitive-behavioral therapy (CBT) did not increase the proportion of patients who were able to successfully discontinue their use of these agents (Oude Voshaar et al. 2003 Vorma et al. 2003). On the other hand, other studies of patients with panic disorder found that CBT facilitated the discontinuation of benzodiazepine use (Otto et al. 1993). Similarly, CBT may be superior to supportive medical management in preventing the reoccurrence of panic attacks in panic disorder patients in whom alprazolam has been tapered (Bruce etal. 1999). 

Bruce TJ, Spiegel DA, Hegel MT Cognitive-behavioral therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation a longterm follow-up of the Peoria and Dartmouth studies. J Consult Clin Psychol 67 151-156, 1999... 

Otto MW, Pollack MH, Sachs GS, et al Discontinuation of benzodiazepine treatment efficacy of cognitive-behavioral therapy for patients with panic disorder. Am J... 

The development of mild forms of anxiety and neuroveg-etative and/or cognitive responses to stress may represent an adaptive evolutionary step against environmentally (external) or self-triggered (internal) threats, but maladaptive reactions have also emerged in human evolution. Thus, anxiety disorders are maladaptive conditions in which disproportionate responses to stress, or even self-evoked responses, are displayed. Anxiety disorders are one of the most frequent psychiatric illnesses, and have a lifetime prevalence of 15- 20% [1, 89]. The most common presentations are generalized anxiety disorder, with a lifetime prevalence rate of close to 5% [1, 89] social anxiety disorder, with very variable lifetime prevalence rates ranging from 2 to 14% [90] panic disorder, with rates from 2 to 4% [1,89] and post-traumatic stress disorder (PTSD), with a prevalence rate close to 8%. Specific phobias, acute stress and obsessive-compulsive behavior are other clinical presentations of anxiety disorders. 

Standardized cognitive behavioral therapy manuals, which ensure adherence to a treatment protocol, have been developed for many different anxiety disorders, including phobias, generalized anxiety, panic, social anxiety, Agoraphobia,... 

The hrst-line treatments for panic disorder are (1) cognitive-behavioral therapy (CBT), (2) benzodiazepines, and (3) SSRIs/SNRls. Each of these three treatment modalities can be nsed independently or in combination. The selection of the primary treatment depends on several factors inclnding severity and frequency of the panic attacks, comorbid illnesses, and patient preference. 

Barlow DH, Gorman JM, Shear MK, Woods SW (2000) Cognitive-behavioral therapy, imipramine, or their combination for panic disorder a randomized controlled trial. JAMA 283 2529-2536... 

An empirical literature on combined treatment is just beginning to emerge. Randomized controlled trials in adults with panic disorder (Barlow et ah, 2000) and major depression (Keller et ah, 2000) suggest advantages for combined drug and cognitive-behavioral... 

Welko vit2. L.A.. Papp, L.A., Cloitre. M., et aL . Cognitive-behavior therapy for panic disorder delivered by psychopharmacologically oriented clinicians J. Nerv. AJent. Dis. 179, 473-477, 1991. 

This syndrome often develops in patients in their twenties, and some, with the more severe form, rarely leave home for periods of many years, or until they are effectively treated by medication, cognitive behavior therapy, or other behavior/psychological therapies. Family studies of panic disorder (PD) find an increased occurrence of attacks in first-degree relatives (2). 

Klosko JS, Barlow DH, Tassinari RB, et al. Alprazolam vs. cognitive behavior therapy for panic disorder a preliminary report. In Hand I, Witchen HU, eds. Panic and phobias. New York Springer Verlag, 1988 54-65. 

Martinsen EW, Olsen T, Tonset E, et al. Cognitive-behavioral group therapy for panic disorder in the general clinical setting a naturalistic study with 1-year follow-up. J Clin Psychiatry 1998 59 437-442. 

Spiegel DA, Bruce TJ. Benzodiazepines and exposure-based cognitive behavior therapies for panic disorder conclusions from combined treatment trials. Am J Psychiatry 1997 154 773-781. 

Loerch B, Graf-Morgenstern M, Hautzineger M, et al. Randomised placebo-controlled trial of moclobemide, cognitive-behavioral therapy and their combination in panic disorder with agoraphobia. Br J Psychiatry 1999 174 205-212. 

Otto MW, Pollack MH, Penava SJ, et al. Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder a clinical case series. Behav Res Ther 1999 37 763-770. 

FIGURE 9-6. Various treatments can be given in combination for panic disorder (i.e., panic combos). The basis of all many combination treatments is a serotonin selective reuptake inhibitor (SSRI). Other antidepressants such as venlafaxine, nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors can all have antipanic actions, although they are second-line treatments, as are the benzodiazepines. On the other hand, benzodiazepines are often added to SSRIs, particularly at the initiation of an SSRI and intermittently when there is breakthrough panic. Cognitive and behavioral psychotherapies can also be added to any of these drug treatments. 

To review the drug treatments of panic disorder, including benzodiazepines, serotonin selective reuptake inhibitors, cognitive behavioral therapy and other treatments. 

Behavioral therapies and cognitive therapies are commonly less effective for the treatment of panic disorder and obsessive compulsive disorder than are the SSRIs. 

Although anxiety disorders, when untreated, can be the cause of substantial personal suffering, disability, and marital and family disruption, the progress made in the therapeutic area for conditions like panic disorder, OCD, and GAD, among other anxiety disorders, makes these conditions very gratifying to treat. Indeed, the skillful use of psychotherapies—cognitive-behavioral therapies appear to be most effective—and medications can produce dramatic and lasting improvement in many patients. 

Also during this time we witnessed the development of novel treatment approaches, such as cognitive-behavioral psychotherapy (Beck 1976) and interpersonal psychotherapy (Klerman, et al. 1984) as a treatment for particular disorders, such as depression and panic disorder. These approaches have appeal, in that they can be somewhat systematically applied (some even provide "canned" formats or "cookbooks"). Also, the methodology is a bit less reliant on the personal characteristics of the therapist. These approaches then lend themselves to a short-term format and can often be conducted in groups. And, finally, these psychotherapies can be more easily studied. Both cognitive-behavioral and interpersonal psychotherapies have a solid track record of effectiveness (as is discussed further in the next chapter). 

Ost, L. A., Westling, B. E. (1995). Applied relaxation vs. cognitive behavior therapy in the treatment of panic disorder. Behavior Research and Therapy, 33, 145-158. 

Wilhelm, F., Margraf, J. (1997). A cognitive-behavioral treatment package for panic disorder with agoraphobia. In W. T. Roth (Ed.), Treating anxiety disorders (pp. 205-244). San Francisco Jossey-Bass. 

Pharmacotherapy is only one of several treatment options for PTSD, especially in view of the great success of cognitive-behavioral therapy (CBT). Medication may be a good choice when patient acceptability of such an approach is high, when comorbid conditions are present that are responsive to pharmacotherapy (e.g. depression, panic disorder, social phobia, and obsessive-compulsive disorder), or when CBT is not applicable. ... 

The patient has physical symptoms and behaviors suggestive of medical and psychiatric disorders, such as fatigue, concentration and cognitive difficulties, confusion, memory impairment, sleep and appetite disturbance, panic attacks, and ritualistic behaviors. 

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