Cognitive-behavioral treatments for panic disorder have been subjected to extensive clinical trials and have been found to be efficacious treatments for treating this condition (Lydiard et al., 2001, APA, 1998). The cognitive-behavioral approach to panic disorder generally involves components of interoceptive exposure and cognitive restructuring. Therapy consists of restructuring of cognitions, exposure, and training in arousal reduction. Patients are educated about the cognitive-behavioral model as a means for helping them to understand their illness. Therapists also work with patients to reappraise catastrophic beliefs by examining them as hypotheses and noting the distortions of the risk of catastrophic outcome. Using interoceptive exposure, somatic sensations similar to panic are induced in patients with a variety of techniques. Repeated exposure to these cues in a safe setting reduces patients' catastrophic experience of them. Patients are also taught skills for coping with these sensations. Finally, patients are taught arousal reduction skills, such as diaphragmatic breathing and relaxation techniques. Some CBT approaches to panic also include in vivo exposure to phobic situations and cue-controlled relaxation exercises.
Despite its consistently demonstrated efficacy for panic disorder, not all patients respond to CBT, nor does it provide total symptom relief for all patients who respond to it. Many long-term outcome studies of CBT for panic disorder report impressive response rates (Marks et al., 1993; Craske et al., 1991; Clark et al., 1994; Fava et al., 1995). Nonetheless, even in the most closely controlled sample that reports the highest response rate (Marks et al., 1993), 38 percent of patients remained symptomatic after completing their CBT trial. Despite the research success of CBT, in clinical practice many panic patients are unable or unwilling to comply with behavioral treatment (APA, 1998; Fava et al., 1995). As many of the groundbreaking CBT studies were performed before the articulation of the NIMH collaborative study on panic disorder that provided specific recommendations about domains of illness that should be monitored during panic disorder treatment trials (Shear and Maser, 1994), few CBT studies have assessed broader quality of life aspects in response to treatment. Additionally, many of the earlier CBT studies suffered from lack of systematic assessment and/or tracking of concomitant nonstudy antipanic medication use that likely contributed to measured outcome. The effects of these untracked medications became particularly important in studies that followed patients over long periods of time (Milrod and Busch, 1996).
In a novel study design using ideographic response, that assessed panic patients who had been treated with CBT over 24 months (assessing longer time periods than are usually evaluated cross sectionally), Brown and Barlow (1995) found that many patients experienced a fluctuating course of panic symptomatology after their CBT trial. Twenty-seven percent of these 63 patients sought further antipanic treatment during the 24-month follow-up interval because of continuing symptoms, but the additional treatment was not helpful. In this study, pretreatment panic severity was the most accurate predictor of poor response. This implies that further research on sicker patients needs to be accomplished.
Very few studies have assessed the efficacy of CBT in addition to antipanic medication. Marks et al. (1993) evaluated the comparative efficacy of alprazolam and CBT, both alone, and in combination in patients with panic and agoraphobia, and found that alprazolam dampened patients' response to CBT. In the recent multicenter treatment trial that extended over 7 years, CBT alone was compared with placebo, imipramine alone, the combination of both CBT and imipramine, and CBT plus placebo for panic disorder (Barlow et al., 2000). In this study, all active treatments produced responses superior to placebo, but the combined treatment cell was not significantly superior to either CBT or imipramine alone after the active treatment phase. However, the combination of CBT and imipramine conferred more substantial advantage than either treatment alone by the end of the 6-month maintenance phase of the study. The major limitation of this important multicenter study is that the patients studied had only mild to moderate agoraphobia with panic, leaving the question open as to how sicker patients with panic disorder would respond to these interventions. CBT has not been extensively studied in populations with combined panic and major depression, but some reports exist that indicate that it may be useful for these patients as well (Lydiard et al., 2001; Barlow et al., 2000).
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