____________________________________________________________________________ Anxiety Disorders
Patient Education An essential step after diagnosis of panic disorder is to review with patients their fears of medical illness and expectations of medical testing and treatment. More than 80% of patients with panic disorder present with a medical symptom, and most are fearful of having a serious condition, such as a stroke. Clini- cal experience suggests that patients benefit from education about panic disorder as the cause of their symptoms and the mechanism by which a mental disorder may provoke physical symptoms. Educational materials for patients may be obtained from the ADAA (https://adaa.org) and the National Institute of Mental Health (https://www.nimh.nih.gov) [129]. PHARMACOTHERAPY The first-line drugs recommended for the treatment of panic disorder are SSRIs or venlafaxine XR [120]. Research suggests that the largest effect size is found with clonazepam, followed by venlafaxine and fluoxetine [224]. Despite a sizeable number of pharmacologic options, less than 50% of patients with panic disorder experience full and sustained remission to first-line medication therapy [287]. SSRI/SNRI The SSRI safety/side effect profile relative to TCAs, MAOIs, and benzodiazepines led to their recommendation as first-line drug options for patients with panic disorder. SSRI side effects occur early in treatment before the therapeutic effects. Many patients with panic disorder are highly sensitive to side effects, and SSRIs should be started at low doses, with dose titration every five to seven days, as tolerated [129]. Following 10 weeks of venlafaxine treatment for panic disorder, patients with few dissociative symptoms during panic attacks showed significantly greater treatment response than patients with greater presence of panic attack-associated dissociative symptoms. These findings suggest that dissociative symptoms accompanying panic disorder negatively impact pharmacologic treatment response. Re-evaluation of dissociative symptoms at the beginning and end of treatment would help in personal- izing therapy [288]. Benzodiazepines A meta-analysis was performed of randomized controlled trials comparing alprazolam to other benzodiazepines in the treat- ment of panic disorder with or without agoraphobia [289]. In the pooled results, there were no significant differences in efficacy between alprazolam and comparator benzodiazepines on improvements in panic attack frequency, anxiety rating scores, or proportion of patients panic attack-free at final evalu- ation. To date, the evidence fails to demonstrate alprazolam superiority to other benzodiazepines for panic disorder treat- ment [289]. Additionally, while alprazolam is one of the most widely prescribed benzodiazepines for the treatment of panic disorder, its clinical use is contentious due to its potential for misuse [290].
TREATMENT OF AGORAPHOBIA Almost all agoraphobia studies reported treatment outcomes of patients with co-occurring panic disorder, as they were not separated into distinct diagnostic entities until the DSM-5 was published in 2013. PSYCHOTHERAPY CBT is the most empirically supported psychosocial treatment for panic disorder with agoraphobia, with a central focus of repeated exposure to feared situations and sensations and application of skills learned in therapy. These include cogni- tive skills to control negative thoughts and somatic skills to control dysregulated physiology during exposure. While CBT has clearly been established as an effective treatment for panic disorder with agoraphobia, the effect sizes are smallest among the anxiety disorders and a large percentage of treatment completers are not panic free or do not reach responder status after treatment. The largest randomized controlled trial to date for panic disorder with agoraphobia found only 32% of those assigned to CBT alone demonstrated strong treatment response at 12 months post-treatment [162]. A small 20-year follow-up of patients with panic disorder with agoraphobia found that completion of medication-free, integrated exposure and psychodynamic treatment resulted in excellent very long- term outcomes for these patients [291]. The relevance of process variables in patient response and out- comes with CBT have been studied. Among 301 patients with panic disorder/agoraphobia, changes in panic symptoms were preceded by changes in catastrophic appraisal and agoraphobic avoidance in all treatment phases, anxiety sensitivity during generalization and follow-up, and psychologic flexibility during exposure therapy. Changes in functioning were preceded by changes in agoraphobic avoidance and psychologic flexibility in all treatment phases, fear of bodily symptoms during gen- eralization/follow-up, and anxiety sensitivity during exposure. The effects of process variables on outcomes differed across treatment phases and outcomes. Agoraphobic avoidance and psychologic flexibility should be therapeutically targeted in addition to cognitive variables [292]. Low remission rates in patients with panic disorder/agorapho- bia following CBT-based therapies has led to the development and evaluation of novel psychotherapies, adjunctive drug therapies, and cognitive enhancer drugs to improve exposure therapy response and remission rates. Novel Psychotherapies The intervention for patients with panic disorder/agoraphobia who are nonresponsive to CBT has generally been pharmaco- therapy, with few studies evaluating a switch to psychotherapy. In one study, patients with previous unsuccessful state-of-the- art treatment were randomized to immediate acceptance and commitment therapy or four-week waiting list with delayed
121
EliteLearning.com/Psychology
Powered by FlippingBook