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This page contains information and summaries of published research that are intended for people with professional training in mental health.  We urge caution since it may be difficult to know how to interpret the information without advanced training in psychology or psychiatry.

We recommend that readers interested in information intended for the general public check other areas of this web site (such as Info for Adults or Info for Children).  They contain similar information, but in a more readable form.  Also, elsewhere we have provided links to other websites that we feel may be helpful.

An Overview of Treatments for Panic Disorder  

(Quick Summary: A specific form of short term cognitive behavioral therapy results in 87% of clients being panic free at the end of treatment and, over a two year follow up period, has low relapse rates.  Behavioral psychotherapy has from 65-70% efficacy.  Antidepressant medications appear to have 35-60% positive outcome, and anti-anxiety medications show 50-60% positive outcomes but in some cases have relapse rates as high as 90%.)

Background on Current Treatments for Panic Disorder 

Although panic disorder can be extremely distressing, fewer than 25% of people with panic disorder seek treatment.  By itself, this fact is disconcerting.  However, two other points make it even more notable.  First, findings indicate that panic disorder tends to have a chronic, fluctuating course.  In other words, a person's symptoms of panic disorder may wax and wane somewhat, but don’t seem to go away over time.  For example, a study was done in 1995 in Oxford, England that included people with panic disorder and people with some symptoms of panic or with infrequent panic.  The author, Dr. Ehlers, found that 92% of people with panic disorder continued to have panic disorder one year after they were first assessed (Other studies have found that only about 14% of people with panic disorder have their symptoms go away spontaneously). 

The second fact that is disconcerting is that in the Oxford study, the author found that the vast majority of people who were getting treatment for their panic disorder were not getting any benefit.  Specifically, there was no difference in symptom remission between people who received “general” treatment in the community and those who received no treatment at all.  Dr. Ehlers noted that although her study was small for community based research, her findings were similar to earlier research that found only about 1 in 23 people get effective treatment. 

In summary, these studies suggest that most people with panic disorder don’t get treatment, and the majority of people who do get treatment may not get effective, specialized treatment.  With those studies in mind, we felt it was important to offer the following information on treatments that have been shown to be effective through controlled research.

What Forms of Psychotherapy Have Been Demonstrated to be Effective?

There is a strong body of treatment research on panic disorder with agoraphobia.  The results in this body of research are, in our opinion, both clear and impressive.  We believe that based on controlled studies the treatment of choice for panic with agoraphobia is a specific variant of Cognitive Behavioral Therapy (CBT; this variant is sometimes referred to as Panic Control Therapy or PCT).  Overall, results from studies have found that 82%-90% of people who received this treatment in different studies were panic-free at the end of treatment.  Studies have also been done that tested this treatment “in real life” in community agencies, and found similarly high success rates.

While the research indicates that CBT offers superior outcomes, there are other treatments which that are commonly used.  Therefore, we will include information both on CBT and on other treatments. 

Efficacy of Different Forms of Psychotherapy

Cognitive Behavioral Therapy (CBT)

Short Term Outcomes for CBT

As mentioned, we believe that the research supports the conclusion that cognitive behavioral therapy is the treatment of choice for panic disorder with agoraphobia.  Most studies find that about 87% (general range of 82-90%) of clients are panic free at the end of treatment.  Usually, the treatment protocols that have been tested are about fifteen sessions long.  One study noted that although these findings are extremely good, they may underestimate the effectiveness of the treatment.  The reason for this underestimation of efficacy is that a significant number of people dropped out of the study because they were panic-free before the treatment was over.

While 87% of people may be panic free at the end of treatment, it is important to note that about 40%-50% of people still had some mild symptoms of anxiety.

As to how treatment affected symptoms of agoraphobia, findings were still very positive, although not as impressive as the outcomes for panic disorder.  Based on a protocol that focuses on in vivo exposure (being gradually exposed in real life to the situations one has been avoiding), 60%-70% of people showed significant clinical improvement.

Long Term Outcomes for CBT

Short-term outcomes for CBT have been consistently good (as mentioned, usually estimated at 87% of people being panic-free at the end of treatment).  In addition, long-term outcomes, overall, have been very positive.  On measures of panic and functioning, most clients have maintained their results (and, on some measures, improved further) when they were assessed three months after finishing treatment, and also twenty-four months following treatment.  One study reported that about 75% of people who underwent CBT were still panic free 24 months after treatment, and the percentage of people who were considered to have “high end state functioning” increased after therapy ended.

Although most people were panic free when they were assessed at follow up, in some studies people have reported that during the two years following the end of treatment they experienced a panic attack.  Also, about 27% of clients who completed treatment went on to seek more treatment.  This group tended to include most of the people who did not benefit from treatment in the first place.  Unfortunately, of the people who did seek additional drug or psychotherapy treatment, the additional treatment did not appear to further reduce their symptoms.

Behavioral Therapy and Relaxation Protocols

Several studies have found that specific types of behavioral therapy (“exposure therapy”) have yielded 60-75% positive outcomes.  While some relaxation protocols have found outcomes as good as behavior therapy, the range of positive outcomes for relaxation protocols appears to range from approximately 32%-75%.  Notably, behavior therapy and relaxation training are both elements that are included in CBT, which is usually estimated to be effective for about 87% of clients.

With behavior therapy, it appears that therapist-aided exposure is more effective than when clients attempt exposure without guidance by a therapist (50-60% improvement rate vs. 25% improvement rate).  However, not all studies agree on this point.  Some research also suggests that other factors that improve outcome include working with a doctoral level practitioner, emphasizing exposure to feared stimuli, and following a systematic approach to programmed practice.   

Supportive Psychotherapy; General Psychotherapy; Psychodynamic Psychotherapy

Probably the most commonly used psychotherapy approaches for treating panic are “general” or supportive therapy and psychodynamic therapy.  Controlled studies on these approaches are few, but have generally indicated that they are among the less effective treatments.  Several community studies have found that people receiving these forms of treatment did no better than people who received no treatment at all. 

Efficacy of Medication

In reading the following information, please keep in mind that our expertise is in psychology, not psychiatry.  Therefore, please check with a psychiatrist for current information on medications.  The information that follows reflects our understanding of published research on medications that are commonly used treatments for panic.

Given the high rate of medication prescriptions for anxiety, it is not surprising that about 50% of people who seek psychotherapy for panic disorder with agoraphobia are already taking medications, usually benzodiazepines or antidepressants.  While these medications are somewhat helpful, studies are consistent in finding that they are not as effective as CBT in the short term, and have much higher relapse rates in the long term.  For example, one Cross National Collaborative Panic Study found that at the end of a year of treatment with the antidepressant imipramine and the benzodiazepine alprazolam (Xanax), only 24% of people were panic free. 

Benzodiazepines

One of the most notable effects of benzodiazepines (such as Alprazolam (Xanax) and Clonazepam (Klonopin) is that when they are first used they can result in a temporary, rapid reduction in anxiety.  There are, however, indications that some people who take these medications may develop psychological dependence, physical tolerance, and side effects.  Because of these factors, some experts have concluded that benzodiazepines are not the treatment of choice for panic disorder with agoraphobia. 

The most commonly prescribed benzodiazepine for panic with agoraphobia is alprazolam (its brand name is Xanax).  When treated with Xanax, about 50%-60% of people who take the medication are temporarily panic free.  There may be some reasons for caution, though.  For example, in one study many of the participants who started taking Xanax could not stop taking it since they had become dependant on it.  When they did stop Xanax, 30% of them had “rebound” panic attacks that were worse than the panic attacks for which they were originally sought treatment.  Finally, when participants were finally taken off Xanax, 90% of them relapsed and started having panic attacks again.

Lower potency benzodiazepines appear to have some problems with low efficacy rates, dependence, and high relapse rates that also indicate that they are probably not the treatment of choice for panic disorder.

Antidepressants

Antidepressants have also been used as treatments for panic disorder with agoraphobia.  Studies have found that antidepressants do not appear to cause the same dependency and rebound symptoms found in benzodiazepines.   In research where the antidepressant imipramine and CBT were compared “head to head," it appeared that CBT was about 25%-35% more effective than imipramine.  As noted above, relapse rates with CBT are low.  With imipramine, studies find that 35%-60% of people relapse when they stop taking medication after the end of treatment.  Additionally, about 20% of people refuse to start taking imipramine, and on average 25%-35% of people stop taking imipramine, often because of side effects.  

A newer class of antidepressants called Serotonin Reuptake Inhibitors (SRIs; they include drugs such as Prozac, Zoloft, and Paxil) appear to have efficacy rates that are similar to imipramine, but fortunately have to have fewer side effects.  Many psychiatrists appear to be using them as a helpful alternative to drugs that have stronger side effects or that may result in dependence.

Beta Blockers

Beta adrenergic blocking agents, or “beta blockers,” are medications that are used to decrease some of the peripheral effects of anxiety such as tremor and sweating.  The majority of studies we reviewed found that beta blockers are ineffective in treating panic. 

Combining Medication and CBT

So, CBT has about an 87% efficacy rate, and medications have about a 50-60% efficacy rate.  What happens if you combine them?  Although one might expect that it would boost the overall success rate, that does not always appear to be the case. 

When anti-anxiety medications such as Xanax are combined with CBT, the majority of studies found that the anxiety medications actually decreased the efficacy of the CBT and resulted in higher relapse rates than for CBT alone.  The conclusion that most researchers have arrived at is that medications such as Xanax actually decrease the long-term effectiveness of CBT, rather than enhancing its effectiveness.

Aside from Xanax, low potency benzodiazepines show no indications of enhancing CBT, and, like Xanax, showed possible indications of interfering with the effectiveness of CBT.

The effect of taking antidepressants during CBT are mixed.  Some findings suggest that it may help with panic, some suggest it may help with depression but not panic, some hint that it might interfere with treatment.  In our opinion, the jury is still out on combining antidepressants with CBT.  

References:

American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Washington D.C.: American Psychiatric Association.

Barlow, D.H. (1988). Anxiety and Its Disorders: The nature and treatment of anxiety and panic. New York: The Guilford Press.

Brown, T.A. & Barlow, D.H. (1995). Long-term outcome in cognitive-behavioral treatment of panic disorder: Clinical predictors and alternative strategies for assessment.  Journal of Consulting and Clinical Psychology, 63,  754-765.

Craske, M.G. & Barlow, D.H. (1993). Panic disorder and agoraphobia. In Clinical Handbook of Psychological Disorders (Ed. D. Barlow).  New York: The Guilford Press.

Craske, M.G., Brown, T.A., & Barlow, D.H. (1991). Behavioral treatment of panic disorder: A two year follow-up.  Behavioral Therapy, 22, 289-304.

Ehlers, A. (1995). A 1-year prospective study of panic attacks: Clinical course and factors associated with maintenance.  Journal of Abnormal Psychology, 104, 164-172.

Michelson, L.K. & Marchione, K. (1991). Behavioral, cognitive, and pharmacological treatments f panic disorder with agoraphobia: Critique and synthesis.  Journal of Consulting and Clinical Psychology, 59, 100-114.

Schmidt, N.B. & Telch, M.J. (1997). Nonpsychiatric medical comorbidity, health perceptions, and treatment outcome in patients with panic disorder.  Health Psychology, 16, 114-122.

Weissman, M. & Marikangas, K.R. (1986). The epidemiology of anxiety and panic disorder: An update.  Journal of Clinical Psychiatry, 47, 11-17.

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The information posted on this site reflects our understanding of peer-reviewed research and generally accepted principles in psychology.  It is not intended to be used for self-treatment or as a substitute for individualized assessment and treatment by a licensed professional, and should not be construed as professional advice.

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