National Institutes of Health Consensus Conference on the Treatment of Panic Disorder Finding
What Are the Current
Treatments? What Are
the Short-Term and Long-Term Effects of Acute and Extended Treatment of
Panic disorder is a treatable condition. The effectiveness of treatment should be evaluated on a number of dimensions: (1) acceptance and tolerance by patients; (2) reduction or elimination of panic attacks, reduction of clinically significant anxiety and disability secondary to phobic avoidance, amelioration of other common comorbid conditions such as depression; and (3) long-term prevention of relapse.
Several different classes of treatment have been shown to be clinically effective, including cognitive and behavioral, pharmacologic, and combinations of the two. The most commonly used behavioral approach is graduated exposure, aimed primarily at reducing phobic avoidance and anticipatory anxiety. Cognitive-behavioral approaches, developed more recently, also treat panic attacks directly. These treatments involve cognitive restructuring, that is, changing of maladaptive thought processes and are generally used in combination with a variety of behavioral techniques, including breathing retraining and activities that target exposure to bodily sensations and external phobic situations. Ongoing assignments to practice the techniques are made by the therapist. These treatments seem to be well accepted by patients and typically involve weekly sessions for 8 to 12 weeks. Initial improvement is noted in many patients within 3 to 6 weeks of beginning treatment. Among the various psychotherapeutic approaches, combined treatments that include cognitive therapy in addition to other techniques appear to be most effective, especially in reducing panic attacks. Longer term followup of these interventions suggests a low relapse rate.
Pharmacologic treatments include tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and high-potency benzodiazepines. A significant proportion of patients do not easily tolerate certain of the tricyclics, whereas benzodiazepines are better accepted. Patients who tolerate tricyclics show significant improvement, with a reduced number of panic attacks during the period of treatment, ranging from 8 to 32 weeks in controlled trials. Benzodiazepines have a rapid onset of action with immediate reduction of panic symptoms, whereas antidepressants require 3 to 6 weeks to achieve therapeutic effect. In addition, the action of benzodiazepines in reducing anxiety between attacks is thought advantageous by some clinicians. Careful titration of medication to effective therapeutic doses with gradual increase in dosage is necessary. Very gradual increases may be particularly important with tricyclics in order to reduce attrition. Longer term duration of treatment probably increases clinical response. Gradual tapering of all medications when treatment ends is strongly indicated. The relapse rate following termination of medication for antidepressants is moderate but is probably higher for benzodiazepines. The relatively high response rate to the control conditions (placebo) needs further examination.
Few studies have examined combined behavioral and pharmacologic methods. There is some evidence that a combination of tricyclics and exposure therapy may have additive effects in the short term, but there is no evidence for long-term advantage over either method alone. Currently, there are few published studies available that assess the combined effect of cognitive and pharmacologic intervention, nor has the optimal sequence of combined methods been examined satisfactorily. Whether using a combination of two effective methods improves upon the effectiveness of either alone or is less effective than either alone is not a settled issue.
There are no controlled data on efficacy of treatment for panic disorder of other widely used approaches, such as psychodynamic psychotherapy.