Panic Disorder : Psychotherapy, Gender

by Food and Drug Administration (FDA)

(Page 3 of 4)

Psychotherapy

Behavioral therapy, aimed at helping patients confront fearful situations and develop coping skills, and cognitive therapy, aimed at treating panic attacks directly by restructuring self-defeating thought processes, may also be incorporated into the treatment plan.

Uhde is not convinced that psychotherapy alone can combat panic disorder. He feels it is of value in helping patients get back on the subway or into their cars or offices and function despite their anxiety. "But that may not be treating the whole syndrome," he says. He points specifically to sleep panic attacks, which he views as probably representing a pure physiological form of panic attack, with no psychological component (see accompanying article, "Why Panic? Search for the Cause").

The NIH panel recommended that any treatment that fails to produce an effect within eight weeks should be reassessed.

One question that looms large is, "When should therapy stop?" Little is known about the long-term course of panic disorder. In most cases, according to the NIH panel, it is a chronic disorder that waxes and wanes in severity. Some people, however, experience only a short-term problem that never recurs, while others may suffer a severe, chronic illness. Patients with agoraphobia tend to have a more severe and complicated illness, according to the panel.

Long-Term Outlook

Much remains to be learned also about the long-term effectiveness of maintenance doses of medication, psychotherapy, and lifestyle changes. Uhde says that, in general, he keeps patients on medication from 6 to 12 months before attempting a drug-free trial. After that, he says, there is a wide range of relapse. "My experience is that approximately 60 percent of patients will require drug treatment again within two years after the medication was stopped."

Regarding Xanax, Laughren says there are inadequate data to guide physicians in how to use the drug beyond the acute treatment phase. "Because panic disorder is a chronic condition," he says, "it may require continued treatment. The labeling suggests that the necessary duration of treatment for patients who respond is unknown, but it recommends that gradual dose reduction and withdrawal be attempted after 'a period of extended freedom from attacks'."

However, the labeling provides only rough guidance about how to withdraw patients from Xanax. "While the necessary research to establish optimal withdrawal strategies has not been done," Laughren says, "clinical experience has led to more conservative recommendations in labeling for withdrawing patients."

At a September 1989 meeting of FDA's Psychopharmacological Drugs Advisory Panel, one participant likened the dilemma of Xanax to taking off in a plane without landing instructions. "He suggested that we know how to get patients up in the air, but it isn't clear how long to keep them there or how best to get them down," says Laughren. "That is, we don't know how long it is necessary to maintain responding patients on the drug, and we don't know how best to withdraw them from treatment."

With all its uncertainties, treatment seems to be working for both Menter and Griffith. Both are in programs at the National Institute of Mental Health. Menter started treatment with imipramine, but is now in a "blind" study, so she doesn't know what drug or combination she's receiving. She still has about two panic attacks a month, but she's not as apprehensive about sleeping now.

"Even though the episodes of panic are as frightening as always," she says, "I know I'm not crazy and I'm trying to do something about it. I can deal with it. One of my biggest fears, I think, was giving in to this thing and maybe one day becoming a crazy person who couldn't take care of herself."

Griffith is taking Xanax and an antidepressant, and is being tapered off Xanax. She hasn't had an attack for several months and is back to traveling to business meetings and eating out at restaurants.

Gender Differences?

Panic disorder affects both men and women. The condition is, however, diagnosed about twice as often in women as in men, and twice as many women as men go on to develop agoraphobia. The reasons why are not known; they may be cultural or biological, or perhaps a combination.

"Physicians are probably more likely to recognize psychological disorders in women, while attributing the same symptoms in men to physical ailments," says Wayne Katon, M.D., professor of psychiatry at the University of Washington Medical School. "Before inquiring about a psychiatric disorder, the examination of the male patient would most likely involve multiple tests such as an echocardiogram or a stress test," he says.

Another reason panic disorder may not be detected as readily in men is their response to the attacks; men are often reluctant to seek help in dealing with emotional stress and attempt to self-treat instead.

"For example," says the National Institute of Mental Health's Thomas W. Uhde, M.D., "there is some evidence to suggest that men resort to the use of alcohol to alleviate their symptoms and eventually are diagnosed with alcoholism rather than panic disorder. In fact, if you look in clinics that specialize in alcoholism and drug addiction, you'll find a high rate of anxiety disorders in patients with alcoholism."

About the Author

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