Anxiety Disorders ____________________________________________________________________________
PSYCHOTHERAPY Behavior Therapy
medications, or TCAs should be monitored for suicide risk; those with severe depression and suicidal ideation may require hospitalization while therapy is initiated [278]. Relapse Prevention Relapse-prevention studies randomized patients showing response to acute treatment to placebo or the same medica- tion/dose. Results in GAD showed significant advantages with continuing the active medications agomelatine, dulox- etine, escitalopram, paroxetine, quetiapine, venlafaxine, or vortioxetine versus switching to placebo for periods of 6 to 18 months [243]. TREATMENT OF PANIC DISORDER Treatment of panic disorder is directed at prevention of panic attacks and reducing preoccupation and anxiety around pos- sibility of impending attacks. SSRIs and SNRIs are effective in preventing panic attacks and relieving anxiety but have no impact on acute symptoms associated with an attack. A treat- ment duration of four to eight weeks is generally required to see a significant reduction in symptoms. A meta-analysis of 54 psychotherapy studies found that eight standard interventions, including supportive psychotherapy, behavioral therapy, cogni- tive therapy, and CBT, were equally efficacious for managing panic disorder, independent of accompanying agoraphobia [125]. Another meta-analysis found that combined psycho- and pharmacotherapy was superior to single-mode therapy, with efficacy verses placebo twice as large as pharmacotherapy alone [279]. The results also suggest that the effects of phar- macotherapy and psychotherapy are largely independent from each other and roughly equal in contribution to the effects of combined treatment. The effects remain strong and significant up to two years post-treatment.
Behavior therapy for panic disorder consists of graded exposure to body sensations that accompany panic (interoceptive expo- sure), to situations perceived as threatening (in vivo exposure, imagery exposure, virtual reality exposure), or both, in order to progressively reduce apprehensive reaction toward them by the patient. Although exposure strategies alone can be effective in the treatment of panic disorder, they do not appear to be a valid alternative to CBT as a first-line treatment [151]. Cognitive Therapy In cognitive therapy for panic disorder, panic attacks are thought to result from the catastrophic misinterpretation of certain bodily sensations. The patient perceives the sensations of normal anxiety response as much more dangerous than they are, such as palpitations viewed as evidence of impend- ing heart attack. Cognitive therapy identifies these negative interpretations of the bodily sensations experienced in panic attacks, suggests alternative non-catastrophic interpretations, and helps the patient test the validity of these alternative interpretations. While cognitive therapy is often combined with behavioral techniques, there is some evidence that train- ing in cognitive procedures in isolation from exposure and behavioral procedures is efficacious in reducing some aspects of panic [151; 280; 281; 282; 283]. CBT CBT assumes that cognitions, behaviors, and emotions are interrelated and combines behavior therapy and cognitive therapy to reduce emotional distress and psychologic symp- toms. CBT for panic disorder consists of psychoeducation, breathing retraining, progressive muscle relaxation, cognitive restructuring, behavioral experiments, interoceptive exposure, and in vivo exposure. A consistent body of evidence supports the efficacy of CBT for panic disorder in individual or group sessions. There is also growing evidence that supports CBT efficacy when therapist-supported and self-administered via the Internet [151; 284; 285]. A network meta-analysis found that the most effective combination of CBT components for treatment of panic disorder was face-to-face administration and graded interoceptive exposure to physiological aspects of the panic response, while muscle relaxation and virtual-reality exposure were the least effective components [286].
The National Collaborating Centre for Mental Health asserts that people who have panic disorder and their families and carers need comprehensive information, presented in clear and understandable language, about the nature of their condition and the
treatment options available. (https://www.nice.org.uk/guidance/cg113. Last accessed April 27, 2025.) Level of Evidence : Expert Opinion/Consensus Statement
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