Nonpharmacologic Therapy

Patients with PD should be counseled to avoid stimulant agents (e.g., decongestants, diet pills, and caffeine) that may precipitate a panic attack. CBT consists of psy-choeducation, continuous panic monitoring, breathing retraining, cognitive restructuring, and exposure to fear cues.50 CBT may involve these features to varying degree. Panic-focused psychodynamic psychotherapy (PFPP) focuses on underlying meaning of panic symptoms (e.g., they have a specific emotional significance) and on current social and emotional functioning.50 PFPP may be used alone or with other modalities. Exposure therapy is useful for patients with phobic avoidance. CBT is considered a first-line treatment of PD, with efficacy similar to that of pharmacotherapy. In a large placebo-controlled trial comparing CBT with imipramine or combination (CBT + imi-pramine), CBT was as effective as the antidepressant after 12 weeks. Patients receiving CBT were less likely to relapse during the 6 months after treatment discontinuation.51,52 In a recent trial of PD with or without agoraphobia, SSRI plus CBT therapy was more effective than SSRI or CBT monotherapy after 9 months of treatment.53

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