With GAD, worry is much more pervasive and tends to cover a variety of life’s domains (eg, finances, work, family). Thus, if the worry is confined to apprehension about having a panic attack or about the implications or consequences of a panic attack, the diagnosis of GAD is excluded. However, a diagnosis of panic disorder is ruled out if a person has GAD and panic attacks, but does not exhibit a month or more of fear of having another attack, worry about the implications of the attack, or significant behavior change (ie, behavioral avoidance). In this case, only GAD is diagnosed, although the presence of panic attacks should be noted as a clinically significant feature.
It is also important to establish whether GAD or panic disorder is primary, because this will probably affect the treatment plan. This assessment can be difficult given the symptom overlap that exists. However, it is often particularly helpful to consider which disorder is having the greatest functional impact or the most potential to impede treatment compliance and outcome. Many patients with moderate to severe panic disorder report that the symptoms are more interfering than GAD symptoms. These patients tend to be more motivated to seek treatment because of the intense fear produced by attacks. They may also be more likely to be referred to treatment because of frequent emergency department (ED) visits. However, there are persons for whom GAD is far more interfering, so this issue warrants consideration.
There is little empirical guidance in the area of treatment planning for comorbid GAD, panic disorder, and panic attacks, but more work is emerging in this area. For example, psychosocial approaches, such as cognitive-behavioral therapy (CBT), are being tailored specifically for treating comorbid GAD and panic disorder.9
CBT is the most researched and effective psychotherapy for both panic disorder and GAD. Findings from CBT trials that target GAD or panic disorder suggest that CBT should be the first-line psychological treatment—regardless of whether panic disorder or GAD is primary.10,11 The elements of empirically supported CBTs for panic disorder and GAD generally include similar techniques, and treatment for the comorbid conditions can include all or some of these elements: psychoeducation, exposure, cognitive restructuring, and relaxation.
Psychoeducation is critically important for individuals with comorbid panic disorder and GAD. The patient’s expectations about treatment are set and treatment goals are developed collaboratively. The next focus of treatment depends on the goals arrived at with the patient. However, keep in mind that research has demonstrated that panic disorder may interfere with GAD treatment more than other comorbid disorders.12 This may be because the intense nature of panic attacks leads to increased functional impairment and obscures the significance of GAD treatment. Frequent and severe panic attacks have the potential to interfere with treatment compliance, particularly if agoraphobia develops. Therefore, it is often prudent to address panic attacks early in treatment.
One way to address panic attacks directly is through interoceptive exposure, which draws on principles of habituation and extinction learning to reduce the occurrence of panic attacks. Generally, during interoceptive exposure, the patient engages in a variety of exercises that induce the feared physical sensations that often precede or accompany a panic attack. Exercises might include spinning in a chair, breathing through a straw, hyperventilating, or walking up stairs. The patient is instructed to continue the exposure until he or she experiences a reduction in anxiety (ie, habituation has occurred).