|In This Special Report:|
The 2 most common anxiety disorders are generalized anxiety disorder (GAD) and panic disorder. Approximately 5.7% of people in community samples will meet diagnostic criteria for GAD in their lifetime; the rate is about 4.7% for panic disorder (with or without agoraphobia).1 GAD—which is characterized by excessive and uncontrollable worry about a variety of topics (along with associated features such as trouble sleeping and impaired concentration)—is often chronic and is associated with significant costs to the individual and to society.2,3
Panic disorder—characterized by recurrent, unexpected panic attacks—can be similarly intractable (particularly when is it accompanied by agoraphobia) and costly.4,5 Panic attacks are discrete periods of intense fear or discomfort that manifest with sweating, trembling, accelerated heart rate, and concern about having another panic attack. Many people experience panic attacks without meeting full diagnostic criteria for panic disorder (about 28.3% lifetime prevalence).6 Furthermore, panic attacks have been identified as a risk factor for various other forms of psychopathology, including GAD.7
Given the widespread occurrence of GAD, panic disorder, and panic attacks, it is not surprising that these conditions are frequently comorbid. An international study of lifetime comorbidities found a high rate (21.8%) of panic disorder and GAD; most people (55.8%) reported that the symptoms of GAD and panic disorder began within 1 year of each other.8 Unfortunately, while effective treatment strategies are available for both panic disorder and GAD, little is known about how to best treat these disorders when they are comorbid.
The first task to effectively address comorbid GAD and panic disorder is to make the appropriate diagnosis. A variety of general medical conditions that mimic features of panic disorder and/or GAD (eg, hyperthyroidism, pheochromocytoma) need to be considered. In addition, somatic and associated symptoms may be present in both GAD and panic disorder; thus it is important to understand the context of these symptoms.
In GAD, somatic symptoms such as muscle tension or feeling “keyed up” or “on edge” may occur, but they present differently than those that arise during a panic attack. Panic attack–related somatic symptoms tend to develop abruptly, then peak and subside relatively quickly, whereas GAD-related somatic symptoms tend to come on more gradually, and are present at a lower level for longer periods. GAD-related somatic symptoms may be experienced as aversive by the individual but generally are not catastrophically misinterpreted (eg, “I am dying”).
In addition to the symptom overlap between GAD and panic attacks, there is overlap between GAD and panic disorder; worry is a component of both disorders. Panic disorder is associated with recurrent panic attacks and worries about future attacks and their consequences or meaning.
1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
2. Noyes R,Woodman C, Garvey MJ, Cook BL. Generalized anxiety disorder vs. panic disorder: distinguishing characteristics and patterns of comorbidity. J Nerv Ment Dis. 1992;180:369-379.
3. Wittchen HU. Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety. 2002;16:162-171.
4. Yonkers KA, Bruce SE, Dyck IR, Keller MB. Chronicity, relapse, and illness—course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up. Depress Anxiety. 2003;17:173-179.
5.Batelaan N, Smit F, de Graaf R, et al. Economic costs of full-blown and subthreshold panic disorder. J Affect Disord. 2007;104:127-136.
6. Kessler RC, Chiu WT, Jin R, et al. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006;63:415-424.
7. Goodwin RD, Lieb R, Hoefler M, et al. Panic attack as a risk factor for severe psychopathology. Am J Psychiatry. 2004;161:2207-2214.
8. Kessler RC, Andrade LH, Bijl RV, et al. The effects of co-morbidity on the onset and persistence of generalized anxiety disorder in the ICPE surveys: International Consortium in Psychiatric Epidemiology. Psychol Med. 2002;32:1213-1225.
9. Labrecque J, Dugas MJ, Marchand A, Letarte A. Cognitive-behavioral therapy for comorbid generalized anxiety disorder and panic disorder with agoraphobia. Behav Modif. 2006;30:383-410.
10. Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76: 1083-1089.
11. Tsao JC, Mystkowski JL, Zucker BG, Craske MG. Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation. Behav Res Ther. 2005;43:959-970.
12. Provencher MD, Ladouceur R, Dugas MJ. Comorbidity in generalized anxiety disorder: prevalence and course after cognitive-behavior therapy [in French]. Can J Psychiatry. 2006;51:91-99.
13. Roemer L, Orsillo SM. Mindfulness- and Acceptance- Based Behavioral Therapies in Practice. New York: Guilford Press; 2008.
14. Roy-Byrne P, Wingerson D, Cowley D, Dager S. Psychopharmacologic treatment of panic, generalizedanxiety disorder, and social phobia. Psychiatr Clin North Am. 1993;16:719-735.
15. Westra HA, Stewart SH. Cognitive behavioural therapy and pharmacotherapy: complementary or
contradictory approaches to the treatment of anxiety? Clin Psychol Rev. 1998;18:307-340.
16. Hidalgo RB,Tupler LA, Davidson JR.An effect-size analysis of pharmacologic treatments for generalized anxiety disorder. J Psychopharmacol. 2007;21:864- 872.
17. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial [published corrections appear in JAMA. 2000;284:2450; JAMA. 2001;284:2597]. JAMA. 2000;283:2529-2536.
18. Arch JJ, Craske MG. Implications of naturalistic use of pharmacotherapy in CBT treatment for panic disorder. Behav Res Ther. 2007;45:1435-1447.
19. Basoglu M, Marks IM, Kiliç C, et al.Alprazolam and exposure for panic disorder with agoraphobia: attribution of improvement to medication predicts subsequent relapse. Br J Psychiatry. 1994;164:652-659.
20. Mathew SJ, Coplan JD, Gorman JM. Management of treatment-refractory panic disorder. Psychopharmacol Bull. 2001;35:97-110.
Arch JJ, Craske MG. Implications of naturalistic use of pharmacotherapy in CBT treatment for panic disorder. Behav Res Ther. 2007;45:1435-1447.
Labrecque J, Dugas MJ, Marchand A, Letarte A. Cognitive-behavioral therapy for comorbid generalized anxiety disorder and panic disorder with agoraphobia. Behav Modif. 2006;30:383-410.