Conclusions
This hypothetical vignette demonstrates several important and common issues in the treatment of comorbid panic disorder and GAD. Julia experienced a typical course of panic disorder and GAD, including onset in the late teens, with a relapsing/remitting course of panic disorder and chronic GAD (with relatively less GAD response to pharmacotherapy). Her initial treatment with an SSRI was unsuccessful because of non-compliance with the treatment regiment secondary to discomfort with the physical sensations associated with medication initiation, a problem that is common in persons with panic disorder.20

Although the panic attacks remitted with the benzodiazepine, there was little effect on the GAD symptoms, and the panic disorder returned on discontinuation (despite slow taper), possibly due to rebound anxiety. A trial of a slowly titrated SSRI helped reduce both symptoms of panic disorder and GAD. This, combined with a course of CBT that focused on reducing symptoms of both disorders, was most effective.

Although combination treatment is common, this practice raises concerns that patients may experience symptom relapse if the medication is withdrawn at some point in the future. During or immediately after SSRI discontinuation, a short booster course of CBT may be indicated to prevent relapse and reinforce previously learned anxiety management skills.

Drug Mentioned in This Article
Alprazolam (Xanax)
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