The American Psychiatric Association Practice Guideline for the Treatment of Patients With Panic Disorder: Recommendations and Controversies

Fredric N. Busch, MD and Barbara L. Milrod, MD

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Comorbidity

There are statements in the guideline that multiple psychiatric illnesses may occur "comorbidly" with panic disorder and may affect treatment. Comorbid depression is frequent, and these cases may be more severe and less responsive to traditional antipanic treatments. Panic patients also have higher than average rates of substance abuse. Panic attacks can occur in the course of posttraumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, and other situational phobias (specific phobias, social phobia, and claustrophobia). It has been estimated that 40% to 50% of panic patients meet DSM-IV criteria for personality disorders, particularly the anxious cluster, including avoidant, obsessive-compulsive, and dependent personality disorders.[17,18] These patients may not be as responsive to treatment or may have higher relapse rates, but the data are unclear.

The guideline notes that uncomplicated panic is relatively uncommon. Some clinicians believe that rather than defining a discrete disorder with a high degree of "comorbidity," panic disorder can be viewed as one element in a syndrome that includes a variety of symptoms and characterologic factors that tend to occur together.[2,3,4] This set of factors is believed to contribute to panic vulnerability, requiring a broader treatment approach than one focused specifically on panic disorder.

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