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Home » Panic Disorder

Psychiatric Times. Vol. 26 No. 2
Pages: 1  2  3  4  
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Special Report - Anxiety Disorders 

Strategies for Assessing and Treating Comorbid Panic and Generalized Anxiety Disorder

Understanding the Differences Between GAD, Panic Disorders, and Panic Attacks

By Kristalyn Salters-Pedneault, PhD | February 1, 2009
Dr Salters-Pedneault is a research associate in the National Center for Posttraumatic Stress Disorder Behavioral Science Division at the VA Boston Healthcare System and an instructor of psychiatry at Boston University School of Medicine. Her research is funded by the Department of Veterans Affairs. She reports no conflicts of interest concerning the subject matter of this article.

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.

(MORE: Achieving Remission in Generalized Anxiety Disorder
)

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treatment is common, this practice raises concerns that patients may experience symptom relapse if the medication is withdrawn at some point in the future.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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Also in this Special Report

The Intricacies of Diagnosis and Treatment

Strategies for Assessing and Treating Comorbid Panic and Generalized Anxiety Disorder

Can Anticonvulsants Help Patients With Anxiety Disorders?

SSRIs as Antihypertensives in Patients With Autonomic Panic Disorder

Achieving Remission in Generalized Anxiety Disorder





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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.
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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.

Evidence-Based References
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.


 
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