While interoceptive exposure is intended to reduce panic, it may also help reduce symptoms of GAD. There are models of GAD and a growing research literature, which suggest that worry and GAD are characterized by a tendency to avoid a variety of emotional experiences, including fear, sadness, anger, and positive emotions.13 There is a distinct possibility that exposure to the uncomfortable emotions and sensations of a panic attack will also reduce the emotional avoidance typical of GAD by introducing or reinforcing the notion that fear and fear-related sensations and thoughts are not harmful.
Another CBT element that may be applied to both panic disorder and GAD symptoms is cognitive restructuring. In panic disorder, cognitive restructuring is used to address catastrophic beliefs about one’s physical sensations and/or panic attacks. For example, many people believe they are dying during a panic attack. In cognitive restructuring, this thought is identified and the patient is encouraged to examine the evidence that this thought is true. The process is much the same when doing cognitive restructuring of worry; an anxious thought is identified (eg, “What will happen if I lose my job?”) and the evidence of the likelihood and/or catastrophic outcome of the thought is examined.
Finally, many CBTs for panic disorder and GAD include a relaxation component that may include skills such as diaphragmatic breathing or progressive muscle relaxation. These skills are popular with clinicians and patients because they are easy to learn (and teach), and often have significant short-term impact on panic symptoms, worry, and GAD somatic symptoms.
Both panic disorder and GAD respond to pharmacological management. Some medications have demonstrated efficacy for both conditions (although they may be FDA-approved for only 1 condition), including some benzodiazepines, tricyclic antidepressants, SSRIs, and serotonin noradrenaline reuptake inhibitors. Other medications, such as azapirones and b-blockers, may alleviate symptoms of GAD but are less effective for panic.14
High-potency benzodiazepines, such as alprazolam(Drug information on alprazolam), have shown superior efficacy for panic symptoms. However, the disadvantages of benzodiazepines, such as abuse potential and rebound anxiety after discontinuation, detract from their overall value in treating comorbid panic disorder and GAD.15 (A recent effect-size analysis suggests that GAD is generally less responsive than panic disorder to pharmacotherapy; also, residual symptoms of GAD may need to be addressed by CBT.16)
Studies that compared treatment responses to medication or CBT have found that while medication may initially produce greater symptom reduction, CBT may produce a more durable response.17 Many practitioners have adopted combination (pharmacotherapy plus CBT) treatment approaches, particularly for those patients with symptoms severe enough to interfere with adherence to psychotherapy. However, there is reason to use this combination approach judiciously. Research has shown that concurrent use of pharmacotherapy and CBT may not be helpful or may be problematic in many individuals with anxiety symptoms. Randomized controlled trials have generally found that combination treatments have limited value over monotherapies for panic disorder, and studies of naturalistic combination treatments for panic disorder have demonstrated poorer outcomes than CBT alone.17,18
There are theoretical reasons to avoid combination therapy for panic disorder and GAD.15 First, it is possible that the phenomenon of state-dependent learning may be implicated in relapse following combination treatment. The extinction learning that occurs during CBT in combination with a medication may not be retrieved as readily from memory once the medication is discontinued. In addition, medication may reinforce a patient’s belief that his internal experiences should be avoided, which may detract from the CBT message that emotions, physical sensations, and thoughts are not harmful and do not need to be avoided. Furthermore, combination therapy may cause patients to attribute symptom reduction to the medication and thereby increase the risk of relapse following medication withdrawal.19
Case Vignette
Julia is a 19-year-old who referred herself for psychiatric treatment following 3 visits to the ED for heart palpitations, shortness of breath, dizziness, and trembling. These attacks began a few months after her father learned he had cancer. All physical causes of the attacks were ruled out. In addition to the panic attacks, Julia reported that she was very worried that she would have another attack in public. She mentioned (when asked) that she worried a lot about many issues in her day-to-day life, including paying her bills, the health of family members, and school. She also reported that for much of her life she had been “an anxious person.” After thorough assessment, panic disorder without agoraphobia and GAD was diagnosed.
Julia was offered pharmacotherapy and CBT but felt that her life circumstances would prevent her from attending therapy appointments regularly. She opted for pharmacotherapy and an SSRI was prescribed for her. At her follow-up appointment she reported that she had decided to stop taking the medication after 2 weeks because it was making her feel jittery. After she switched to a benzodiazepine, the number of panic attacks was significantly reduced, as were the somatic symptoms of GAD. Nevertheless, she continued to worry excessively.
After 1 year of therapy, Julia noted that her life circumstances had become less stressful. The benzodiazepine dosage was slowly tapered, but within 1 week after the medication had been discontinued, Julia had another panic attack. Her psychiatrist decided to try another SSRI but this time at a much lower initial dosage. She was also referred to a CBT therapist for treatment of both panic disorder and GAD.
Julia was quite motivated for CBT treatment and complied with all therapy elements. While she was initially apprehensive about interoceptive exposure exercises, she was willing to try them and did report less fear of her physical sensations after completing these exercises. She also reported that the cognitive restructuring and relaxation skills helped her feel greater mastery over her anxiety and worry. At the conclusion of the 16 sessions of CBT, Julia no longer met diagnostic criteria for panic disorder but still met criteria for GAD (although she reported reduced severity of symptoms). One year after CBT treatment, she was continuing to take the SSRI and was still experiencing some symptoms of GAD but had not had a panic attack since completing CBT.
