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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Cognitive Behavioral Therapy (CBT)

CBT is a highly recommended treatment modality in the guideline on the basis of randomized, placebo-controlled trials. CBT includes a variety of approaches: psychoeducation, continuous panic monitoring, breathing retraining, development of anxiety management skills, cognitive restructuring, and in vivo exposure to fear cues. The guideline notes that it is unknown whether specific approaches are helpful for particular types of patients. Noting that CBT effectiveness is supported by "extensive and high-quality data" (p 2), the guideline suggests that if other psychotherapies are used, "supplementation with (or replacement by) either CBT or an antipanic medication should be strongly considered if there is no significant improvement within 6-8 weeks" (p 2). It is not currently possible to identify which patients may benefit from combined CBT and medication, although it may be helpful in patients with an incomplete response or severe agoraphobia. Data suggest that CBT can also aid in discontinuation of a benzodiazepine.

After an acute 12-week phase of treatment with CBT, frequency of visits is generally tapered and then discontinued. It is unknown whether additional "booster" sessions are helpful in preventing relapse. Patients who relapse can be re-treated with CBT or receive a medication trial. Patients with no improvement after 6 to 8 weeks should be re-evaluated with regard to diagnosis and treatment approach or considered for a combined treatment approach. Benzodiazepines may be valuable as an adjunctive treatment for rapid symptom relief, with attempts to minimize dose and duration as other treatments take effect.

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