Anxiety Disorders ____________________________________________________________________________
acceptance and commitment therapy; they were then fol- lowed for up to six months. Significantly greater changes in functioning and symptomatology were found in patients who received immediate acceptance and commitment therapy versus those on the waiting list, and medium-to-large effect sizes were maintained for six or more months. Acceptance and commitment therapy may be a viable treatment option for treatment-resistant panic disorder with agoraphobia [293]. A long-term study of patients with panic disorder and agora- phobia found catastrophic beliefs to be an important mediator of change. Of 46 patients with panic disorder/agoraphobia randomized to cognitive or guided mastery therapy, 31 (67.4%) medication-free patients who completed treatment were fol- lowed up to 18 years post-treatment. Both groups showed a large effect size for avoidance of situations when alone, and 56.5% no longer met diagnostic criteria for panic disorder or panic disorder with agoraphobia. Patient outcomes between the two treatments were comparable, although guided mastery was associated with greater beneficial changes in catastrophic beliefs and self-efficacy. Greater reduction in panic-related beliefs about physical and mental catastrophes predicted lower anxiety level at follow-up [294]. Combination Therapy Following paroxetine plus CBT (once weekly for 12 weeks), par- oxetine plus CBT and virtual reality exposure (four sessions), or paroxetine only, the six-month follow-up of 99 patients with panic disorder/agoraphobia showed reduced anxiety levels in all three groups and greatest reduction in both CBT groups. The virtual reality exposure group showed greater improvement in confronting agoraphobic stimuli, although medication ces- sation and dropout were high [295]. The one-year follow-up of patients with panic disorder with and without agoraphobia treated with CBT, SSRI, or CBT and SSRI found that panic attack frequency significantly declined in all groups and both SSRI groups improved significantly faster than CBT [296]. The SSRI gains were maintained after tapering. Panic frequency in patients with moderate-to-severe agoraphobia decreased more rapidly with CBT plus SSRI than either sole treatment. With CBT alone, improvement was slower than with SSRI or CBT plus SSRI. SSRI monotherapy was concluded sufficient for patients with panic disorder with no or mild agoraphobia, while patients with panic disorder and moderate-to-severe agoraphobia should receive CBT plus SSRI [296]. PHARMACOTHERAPY An efficacy analysis of drug therapy trials in the treatment of panic disorder with agoraphobia was published in 2011 [86]. It concluded that panic attack recurrence worsens agoraphobic behaviors in panic disorder with agoraphobia and disrupts agoraphobia remission. This suggests that using panic attack- blocking medication in patients with panic disorder/agora- phobia at risk of panic attack recurrence is more appropriate than CBT alone.
The meta-analysis also found that paroxetine displayed high efficacy in panic and phobic symptoms and agoraphobia sever- ity reduction. This efficacy was similar to CBT in reducing agoraphobic behaviors and superior to CBT in reducing panic attacks during acute treatment phase [86]. Adding paroxetine to CBT in patients with poor CBT response is significantly more effective in improving agoraphobic behaviors than add- ing placebo, so it is strongly suggested to add paroxetine for patients lacking adequate response or panic attack reduction with CBT [86]. Sertraline, citalopram, and escitalopram are also effective in the treatment of panic disorder/agoraphobia. A randomized controlled trial compared treatment with an SSRI (paroxetine or citalopram) to continued treatment with CBT in a sample of 68 individuals with panic disorder (with or without agoraphobia) who had not responded to an initial course of CBT [297]. Participants were randomized to three months of treatment and then followed for an additional nine months. Those who responded to treatment after 3 months were maintained on the treatment until 12-month follow-up. Participants receiving an SSRI showed significantly lower panic disorder symptoms compared with continued CBT at three months, suggesting a greater improvement in panic disorder symptoms when patients are switched to an SSRI after failure to respond to an initial course of CBT [297]. The TCA clomipramine has similar panic/phobic efficacy to paroxetine and sertraline. Imipramine is more effective than placebo in long-term maintenance, but less effective than sertraline in short-term outcomes. Venlafaxine is effective in reducing panic and phobic symptoms [86]. Reboxetine is more effective in the treatment of panic/phobia than placebo. It has similar efficacy to paroxetine in phobic avoidance and antici- patory anxiety, but lower efficacy in reducing panic attacks. Fluvoxamine has only inconsistent efficacy in the treatment of panic disorder/agoraphobia, and while fluoxetine may be used to address panic attacks, it has limited efficacy for panic disorder/agoraphobia [86]. These results suggest noradrenergic system involvement in modulating panic disorder with agoraphobia avoidance behav- iors, but serotonergic system targeting is important to decrease panic attacks. Re-analysis of prior pharmacologic randomized controlled trial data found higher efficacy with sertraline and clomipramine in reducing agoraphobic symptoms than paroxetine, fluvoxamine, or citalopram. This may reflect the added dopaminergic modulation of these agents beyond their primary serotonergic activity [86]. A novel treatment approach is based on multiple findings of balance system dysfunction in patients with panic disorder/ agoraphobia. An open study found citalopram influenced the balance system in these patients by improving postural stability, as measured by static posturography. Compared with baseline scores, most patients whose balance system function improved were no longer agoraphobic, while those whose posturography scores remained abnormal continued to be agoraphobic. These findings suggest the involvement of balance system dysfunction
122
EliteLearning.com/Psychology
Powered by FlippingBook