Further Exploration of Treatment Response in Latinos with Comorbid Asthma and Panic Disorder: A Brief Report of HRV and ETCO2 as Potential Mediators of Treatment Response.

Heart rate variability (HRV) and end tidal CO2 (ETCO2) in relation to treatment response have not been studied in Latino populations or in comorbid asthma and panic disorder (PD). An extension of previously published research, the current study explored psychophysiological variables as possible mediators of treatment response. Latino treatment completers (N = 32) in the Bronx with asthma-PD received either Cognitive-Behavioral Psychophysiological Therapy (CBPT) or Music Relaxation Therapy (MRT). CBPT included HRV-biofeedback (HRVB); in-the-moment heart rate data to help an individual learn to influence his/her own heart rate. The sample was primarily female (93.8%) and Puerto Rican (81.25%). Treatment groups did not differ on demographics, except for less education in CBPT. The Panic Disorder Severity Scale (PDSS) and Asthma Control Questionnaire (ACQ) assessed changes in symptoms. HRV and ETCO2 were measured at four of eight therapy sessions. Baseline ETCO2 and changes in HRV from first to last of psychophysiology sessions were investigated as mediators of change on ACQ and PDSS. Mixed model analyses indicated in the CPBT group, changes in both asthma control and PD severity were not mediated by changes in HRV. In the CBPT and MRT groups combined, changes in PD severity were not mediated by baseline ETCO2. These findings may be due to the brevity of HRVB in CBPT, multiple treatment components, ETCO2 not directly targeted, and/or unique physiological pathways in Latinos with asthma-PD.

MAOA and mechanisms of panic disorder revisited: from bench to molecular psychotherapy.

Panic disorder with agoraphobia (PD/AG) is a prevalent mental disorder featuring a substantial complex genetic component. At present, only a few established risk genes exist. Among these, the gene encoding monoamine oxidase A (MAOA) is noteworthy given that genetic variation has been demonstrated to influence gene expression and monoamine levels. Long alleles of the MAOA-uVNTR promoter polymorphism are associated with PD/AG and correspond with increased enzyme activity. Here, we have thus investigated the impact of MAOA-uVNTR on therapy response, behavioral avoidance and brain activity in fear conditioning in a large controlled and randomized multicenter study on cognitive behavioral therapy (CBT) in PD/AG. The study consisted of 369 PD/AG patients, and genetic information was available for 283 patients. Carriers of the risk allele had significantly worse outcome as measured by the Hamilton Anxiety scale (46% responders vs 67%, P=0.017). This was accompanied by elevated heart rate and increased fear during an anxiety-provoking situation, that is, the behavioral avoidance task. All but one panic attack that happened during this task occurred in risk allele carriers and, furthermore, risk allele carriers did not habituate to the situation during repetitive exposure. Finally, functional neuroimaging during a classical fear conditioning paradigm evidenced that the protective allele is associated with increased activation of the anterior cingulate cortex upon presentation of the CS+ during acquisition of fear. Further differentiation between high- and low-risk subjects after treatment was observed in the inferior parietal lobes, suggesting differential brain activation patterns upon CBT. Taken together, we established that a genetic risk factor for PD/AG is associated with worse response to CBT and identify potential underlying neural mechanisms. These findings might govern how psychotherapy can include genetic information to tailor individualized treatment approaches.

Therapygenetics: anterior cingulate cortex-amygdala coupling is associated with 5-HTTLPR and treatment response in panic disorder with agoraphobia.

Variation in the 5'-flanking promoter region of the serotonin transporter gene SLC6A4, the 5-HTT-linked polymorphic region (5-HTTLPR) has been inconclusively associated with response to cognitive-behavioural therapy (CBT). As genomic functions are stronger related to neural than to behavioural markers, we investigated the association of treatment response, 5-HTTLPR and functional brain connectivity in patients with panic disorder with agoraphobia (PD/AG). Within the national research network PANIC-NET 231 PD/AG patients who provided genetic information underwent a manualized exposure-based CBT. A subset of 41 patients participated in a functional magnetic resonance imaging (fMRI) add-on study prior to treatment applying a differential fear conditioning task. Neither the treatment nor the reduced fMRI sample showed a direct effect of 5-HTTLPR on treatment response as defined by a reduction in the Hamilton Anxiety Scale score ≥50 % from baseline to post assessment. On a neural level, inhibitory anterior cingulate cortex (ACC)-amygdala coupling during fear conditioning that had previously been shown to characterize treatment response in this sample was driven by responders with the L/L genotype. Building upon conclusive evidence from basic and preclinical findings on the association of the 5-HTTLPR polymorphism with emotion regulation and related brain connectivity patterns, present findings translate these to a clinical sample of PD/AG patients and point towards a potential intermediate connectivity phenotype modulating response to exposure-based CBT.

5HTT is associated with the phenotype psychological flexibility: results from a randomized clinical trial.

Adaption to changing environments is evolutionarily advantageous. Studies that link genetic and phenotypic expression of flexible adjustment to one's context are largely lacking. In this study, we tested the importance of psychological flexibility, or goal-related context sensitivity, in an interaction between psychotherapy outcome for panic disorder with agoraphobia (PD/AG) and a genetic polymorphism. Given the established role of the 5HTT-LPR polymorphism in behavioral flexibility, we tested whether this polymorphism (short group vs. long group) impacted therapy response as a function of various endophenotypes (i.e., psychological flexibility, panic, agoraphobic avoidance, and anxiety sensitivity). Patients with PD/AG were recruited from a large multicenter randomized controlled clinical trial on cognitive-behavioral therapy. Pre- to post-treatment changes by 5HTT polymorphism were analyzed. 5HTT polymorphism status differentiated pre- to post-treatment changes in the endophenotype psychological flexibility (effect size difference d = 0.4, p < 0.05), but none of the specific symptom-related endophenotypes consistently for both the intent-to-treat sample (n = 228) and the treatment completers (n = 194). Based on the consistency of these findings with existing theory on behavioral flexibility, the specificity of the results across phenotypes, and the consistency of results across analyses (i.e., completer and intent to treat), we conclude that 5HTT polymorphism and the endophenotype psychological flexibility are important variables for the treatment of PD/AG. The endophenotype psychological flexibility may help bridge genetic and psychological literatures. Despite the limitation of the post hoc nature of these analyses, further study is clearly warranted.

Citizenship and recovery: two intertwined concepts for civic-recovery.

BACKGROUND: Validation of the psychometric properties of a new measure of citizenship was required for a research project in the province of Quebec, Canada. This study was meant to study the interplay between recovery- and citizenship-oriented supportive employment. As recovery and citizenship were expected to be two related concepts, convergent validity between the Citizenship Measure (CM) and the Recovery Assessment Scale (RAS) was tested. METHODS: Study objectives were to: 1) conduct exploratory factor analyses on the CM and confirmatory factor analysis on the RAS tools (construct validity), 2) calculate Cronbach's alphas for each dimension emerging from objective 1 (reliability), and 3) calculate correlations between all dimensions from both tools (convergent validity). Data were collected from 174 individuals with serious mental illness, working in social firms. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, post traumatic stress disorder and borderline personality disorder. RESULTS: Five factors emerged from the exploratory factor analysis of the CM, with good reliability. Confirmatory factor analyses showed that the short and the long versions of the RAS present satisfactory results. Finally, the correlation matrix indicated that all dimensions from both tools are significantly correlated, thus confirming their convergent validity. CONCLUSIONS: This study confirms the validity and reliability of two tools, CM and RAS. These tools can be used in combination to assess citizenship and recovery, both of which may be combined in the new concept of civic-recovery.

Severity of anxiety and work-related outcomes of patients with anxiety disorders.

BACKGROUND: This study examined associations between anxiety and work-related outcomes in an anxiety disorders clinic population, examining both pretreatment links and the impact of anxiety change over 12 weeks of treatment on work outcomes. Four validated instruments were used to also allow examination of their psychometric properties, with the goal of improving measurement of work-related quality of life in this population. METHODS: Newly enrolled adult patients seeking treatment in a university-based anxiety clinic were administered four work performance measures: Work Limitations Questionnaire (WLQ), Work Productivity and Activity Impairment Questionnaire (WPAI), Endicott Work Productivity Scale (EWPS), and Functional Status Questionnaire Work Performance Scale (WPS). Anxiety severity was determined using the Beck Anxiety Inventory (BAI). The Clinical Global Impressions, Global Improvement Scale (CGI-I) was completed by patients to evaluate symptom change at a 12-week follow-up. Two severity groups (minimal/mild vs. moderate/severe, based on baseline BAI score) were compared to each other on work measures. RESULTS: Eighty-one patients provided complete baseline data. Anxiety severity groups did not differ in job type, time on job, job satisfaction, or job choice. Patients with greater anxiety generally showed lower work performance on all instruments. Job advancement was impaired for the moderate/severe group. The multi-item performance scales demonstrated better validity and internal consistency. The WLQ and the WPAI detected change with symptom improvement. CONCLUSION: Level of work performance was generally associated with severity of anxiety. Of the instruments tested, the WLQ and the WPAI questionnaire demonstrated acceptable validity and internal reliability.

[Workplace-related anxiety, workplace phobia and disorders of participation]. / Arbeitsplatzängste und Arbeitsplatzphobie und ihre Auswirkungen auf die berufliche Partizipation.

Work is an important domain of life. It is therefore clear that problems at the workplace and mental disorders will have negative interactions. Job-related anxieties are of special importance as any workplace causes or intensifies anxiety by its very nature. A common final pathway of mental disorders in general and workplace-related anxieties in particular is workplace phobia. Similarly to agoraphobia, it is characterised by panic when approaching or even thinking of the stimulus, in this case the workplace. Workplace phobia has serious negative consequences for the further course of illness. It impairs the ability to work, and can lead to sick leave and early retirement. It requires special therapeutic interventions. This paper describes workplace-related anxieties and workplace phobia and gives a conceptual framework for their understanding.

A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care.

BACKGROUND: Treated anxiety increased in the UK by over 30% since 1994. Medication and psychological treatment is most common, but outcomes are sometimes poor, with high relapse rates. Lifestyle has a potential role in treatment, but is not considered in clinical guidelines. Panic disorder is potentially influenced by lifestyle factors. METHODS: 16 week unblinded pragmatic randomised controlled trial in 15 East of England primary care practices (2 Primary Care Trusts). Participants met DSM-IV criteria for panic disorder with/without agoraphobia. Follow-up at 20 weeks and 10 months. Control arm, unrestricted routine GP care. Trial Arm, Occupational therapy-led lifestyle treatment comprising: lifestyle review of fluid intake, diet pattern, exercise, caffeine, alcohol and nicotine; negotiation of positive lifestyle changes; monitoring and review of impact of changes. PRIMARY OUTCOME MEASURE: Beck Anxiety Inventory. DATA ANALYSIS: Intention-to-treat analysis provided between-group comparisons using analysis of co-variance. Bonferroni method to adjust p-values. RESULTS: From 199 referrals, 36 GP care and 31 lifestyle arm patients completed to final follow-up. Significantly lower lifestyle arm BAI scores at 20 weeks (p<0.001), non-significant (p=0.167) at 10 months after Bonferroni correction. 63.6% lifestyle arm, and 40% GP arm patients (p=0.045) panic-free at 20 weeks; 67.7% and 48.5% (p=0.123) respectively at 10 months. LIMITATIONS: Final study size/power calls for caution in interpreting findings. CONCLUSIONS: A lifestyle approach may provide a clinically effective intervention at least as effective as routine GP care, with significant improvements in anxiety compared with routine GP care at the end of treatment. Further study is required before suggesting practice changes.

Comorbidity with axis I anxiety disorders in remitted psychotic patients 1 year after hospitalization.

INTRODUCTION: Comorbid anxiety disorders are frequently encountered in psychoses and mainly assessed during the hospitalization. METHODS: Comorbidity was investigated in 98 patients with schizophrenia, schizoaffective, or bipolar disorder, previously hospitalized for psychotic symptoms. Assessments, including Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Brief Psychiatric Rating Scale, and Clinical Global Impressions Scale, were performed during hospitalization (t0) and subsequently in a phase of remission (t1). Comorbidity was assessed at t1 only. RESULTS: One or more comorbid anxiety diagnoses were made in 46 (46.9%) patients. Of these, 15 (32.6%) received multiple anxiety diagnoses, while 31 (67.4%) single anxiety diagnoses. Schizophrenic patients had a rate of social anxiety disorder (SAD) higher (P<.05) than the others. Patients assessed with panic disorder or with obsessive-compulsive disorder at t1 showed significantly greater severity of illness at t0; patients with SAD demonstrated greater severity at t1. No significant differences in the rates of individual anxiety disorders were found in patients treated with typical or atypical antipsychotics or with both. CONCLUSION: Anxiety disorders, particularly obsessive-compulsive disorder, panic disorder and SAD, seem to be frequently comorbid in remitted psychotic patients; SAD would be more prevalent in schizophrenia and might negatively impact the course of the illness.

A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias - One size fits all.

BACKGROUND AND OBJECTIVES: Many individuals with anxiety disorders do not receive professional treatment. Internet interventions have shown to be effective in the treatment of anxiety. The present randomized controlled trial was designed to examine the effectiveness of a short-term (4-week) Internet intervention in treating panic disorder, agoraphobia, social anxiety disorder, and specific phobias ('ConfID'). We addressed the questions of whether this transdiagnostic program would affect these disorders to varying degrees and whether there would be moderators of effectiveness. METHODS: Adults who were recruited in online forums for anxiety underwent an online baseline assessment (N = 179) and were randomized either to the intervention group (ConfID) or the control group (care as usual). Online post-assessment took place 4 weeks later. The primary outcome was assessed with the Beck Anxiety Inventory (BAI); the secondary outcomes targeted the disorder-specific symptoms, depression, and somatization. RESULTS: Participants in the intervention group showed a significantly stronger anxiety reduction compared to participants receiving care as usual (small-to-medium effect size between groups in intention-to-treat analysis). The treatment effect was similar for the different disorders and was moderated by participants' attitudes towards Internet interventions. Secondary outcomes yielded effect sizes in the medium range. LIMITATIONS: Moderate treatment adherence, lack of measures beyond online self-reports, and unavailability of long-term results. CONCLUSIONS: The study provides further evidence that transdiagnostic Internet interventions are promising in reducing the existing treatment gap in individuals with panic disorder and phobias. Results extend previous findings by showing that significant effects can also be reached by comprehensive short-term programs and that the effects might be moderated by participants' attitudes towards Internet interventions.

Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia.

INTRODUCTION: Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment-specific effects on symptoms and neurofunctional correlates. EXPERIMENTAL PROCEDURES: We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29). RESULTS: Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups. DISCUSSION: This study demonstrates that therapist-guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment.

Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care.

OBJECTIVE: Recent policy has focused on documenting and reducing ethnic disparities in availability and quality of health care. The authors examined differences by ethnic status in unmet need for alcoholism, drug abuse, and mental health treatment. METHOD: Data were from a follow-up survey of adult respondents to a 1996-1997 national survey. Non-Hispanic whites, African Americans, and Hispanics were compared in access to alcoholism and drug abuse treatment and mental health care (primary or specialty), unmet need for care, satisfaction with care, and use of active treatment for alcoholism, drug abuse, and mental health problems in the prior 12 months. RESULTS: A total of 31.9% of whites, 28.1% of African Americans, and 30.1% of Hispanics had some alcoholism, drug abuse, and mental health care, mostly in primary care. Among those with perceived need, compared to whites, African Americans were more likely to have no access to alcoholism, drug abuse, or mental health care (25.4% versus 12.5%), and Hispanics were more likely to have less care than needed or delayed care (22.7% versus 10.7%). Among those with need, whites were more likely than Hispanics or African Americans to be receiving active alcoholism, drug abuse, or mental health treatment (37.6% versus 22.4%-25.0%). CONCLUSIONS: The authors document greater unmet need for alcoholism and drug abuse treatment and mental health care among African American and Hispanics relative to whites. New policies are needed to improve access to and quality of alcoholism, drug abuse, and mental health treatment across diverse populations.

Panic disorder in a Spanish sample of 89 patients with pure alcohol dependence.

High rates of anxiety disorders, including panic disorder (PD), have been found in patients suffering from alcohol dependence (AD). It has been suggested that alcoholic subjects with PD represent a more severe subgroup of patients. Eighty-nine patients with 'pure' AD (without abuse of other drugs) were examined and compared for the presence of PD. Several clinical scales were administered to assess symptomatology and severity. Twenty-three patients (25.8%) met the criteria for PD. The mean age at onset for alcohol use was 18.7 versus 28.5 years for PD onset. Our finding of an earlier onset for alcoholism than for PD in a sample of Spanish patients illustrates the potential importance of transcultural factors. These patients were more likely to be women and to have first-degree relatives with PD. Overall, alcoholic patients with comorbid PD showed greater clinical severity. They were found to have more comorbidity with axis I disorders (major depression and dysthymia), greater clinical severity, and a history of more suicide attempts.

Medication use and the assessment of agoraphobic avoidance.

Many anxiety disorder patients who present for behaviour therapy are already taking anxiolytic medications. The present study added a new subscale to the Mobility Inventory labelled 'Without Medication' to assess possible reliance on medication for coping with phobic situations. 121 Patients with panic-related disorders were administered the scale. The results supported the reliability and validity of the existing Mobility Inventory subscales in general and of the new subscale in particular. It appears to reliably assess a clinically important domain that is not measured in traditional self-report measures of phobic avoidance.

Suicide, chemical abuse, and panic attacks: a preliminary report.

Seventy-two chemical abuse patients who either met DSM-III-R criteria for panic disorder (PD), experienced infrequent panic attacks (IP), or did not experience panic attacks in the past year (NP) were compared on several dimensions. PD subjects were more likely to be female and to have attempted suicide. Patients who had attempted suicide, when compared to non-suicide attempters, were more likely to be classified as having PD, and be non-married. IP and NP groups did not differ on any of the relevant variables. The similarities of these findings to those obtained with PD and chemical abuse patients are discussed.

Impact of panic attacks on rehabilitation and quality of life among persons with severe psychotic disorders.

OBJECTIVE: The study evaluated data from a sample of persons with severe psychotic disorders to determine whether those with and without comorbid panic attacks differed in rates of comorbidity of other psychiatric disorders, in quality of life, and in rehabilitation outcomes. METHODS: A total of 120 individuals with psychotic disorders were assessed with the Center for Epidemiologic Studies-Depression scale, the Structured Clinical Interview for DSM-III-R, the General Health Questionnaire, the Global Assessment of Functioning scale, and several quality-of-life measures at baseline and four and a half months after they had participated in a social rehabilitation program. Multivariate analyses of variance and Pearson's chi square tests were used to compare baseline and follow-up scores between individuals who did and did not have panic attacks. RESULTS: Eighteen (15 percent) of the participants who had severe psychotic disorders also had panic attacks. Participants with this type of comorbidity had significantly higher rates of major depressive disorder, specific phobia, sedative abuse, polysubstance abuse, other substance abuse, and anorexia nervosa than participants who did not have panic attacks. Participants who had panic attacks also had poorer rehabilitative outcomes and poorer quality of life at baseline and at follow-up than participants who did not have panic attacks. CONCLUSIONS: These data are the first to show that comorbid panic attacks are associated with poorer rehabilitative outcomes and poorer quality of life among individuals with severe psychotic disorders than among those who have psychotic disorders without panic attacks. Panic attacks may be a valuable prognostic indicator among persons with psychotic disorders and may have implications for treatment and rehabilitation.

An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women.

OBJECTIVE: Social phobia is a chronic disorder with a higher prevalence among women than men. Data from an eight-year longitudinal study were analyzed to investigate the course of social phobia and to explore potential sex differences in the course and characteristics of the illness. METHODS: Data were analyzed from the Harvard/Brown Anxiety Research Program, a naturalistic, observational study begun in 1989 in which patients with social phobia are assessed every six to 12 months. Treatment was observed but not prescribed by the program personnel. Data on comorbidity, remission, and health-related quality of life were collected for 176 patients with social phobia. RESULTS: Only 38 percent of women and 32 percent of men experienced a complete remission during the eight-year study period, a difference that was not significant. A larger proportion of women than men had the generalized form of social phobia, although the difference was not significant. Women were more likely to have concurrent agoraphobia, and men had a higher rate of comorbid substance use disorders. Social phobia had a more chronic course among women who had low Global Assessment of Functioning scores and a history of suicide attempts at baseline than among men who had these characteristics. Health-related quality of life was similar for both men and women, except that women were slightly but significantly more impaired in household functioning. CONCLUSIONS: The chronicity of social phobia was striking for both men and women. Although remission rates did not differ significantly between men and women, clinicians should be alert to the fact that women with poor baseline functioning and a history of suicide attempts have the greatest chronicity of illness.

The long-term course of panic disorder--an 11 year follow-up.

BACKGROUND: The purpose of this study was to assess the naturalistic long-term course of panic disorder over a period of 11 years. METHOD: Thirty DSM-III-R panic disorder patients, who had suffered from panic disorder for 6 years on average and who had taken part in an 8-week multicenter drug trial, were included in the intent-to-follow-up group to be reinterviewed 11 years after the end of the trial. At baseline and at follow-up the same instruments were used to assess frequency of panic attacks, level of phobic avoidance, and disabilities. Treatments received during the follow-up period and attempted suicides were assessed with a structured interview. Periods of well-being during the follow-up period were elicited retrospectively with a specifically designed longitudinal chart. RESULTS: Twenty-four patients could actually be reinterviewed after 11.3 years. While at baseline all patients had suffered from panic attacks and had been severely disabled on a number of measures, 66.7% had no panic attack during the year before follow-up. During the month before follow-up 87.5% had no panic attack, and 54% showed no or only mild phobic avoidance. In the areas of work and family life 90% showed no or only mild disabilities, whereas in the area of social life this percentage was lower (67%). Thirty-three percent of the patients were completely remitted according to a composite remission criterion. CONCLUSIONS: Panic disorder is not a uniformly chronic and progressing disorder. Over a period of 11 years there is a good chance of recovery from panic attacks and disabilities, and full remission is also possible.

Behavior therapy for vestibular rehabilitation.

Patients with panic disorder and patients with vestibular disorders often share symptomatology, such as dizziness, spatial disorientation, and anxiety in particular environments. Because of the similar clinical presentations, it is not always apparent whether these symptoms are due primarily to a vestibular disorder or to panic disorder. Depending on where and how these patients enter the medical system, their symptoms may be remedied by treatment from behavioral therapists or physical therapists trained in vestibular rehabilitation. Although vestibular rehabilitation developed independently of behavioral treatment for anxiety disorders, there are remarkable similarities in treatment conceptualization and implementation. For example, both use exposure procedures designed to produce habituation of dizziness and disorientation, as well as enhancing functional compensation. Furthermore, there appears to be a subset of individuals with panic disorder who also have vestibular pathology and thus, may benefit from both interventions. In this paper, similarities and differences in the clinical presentation, treatment goals, and specific interventions for patients with panic disorder or vestibular pathology is examined, and future implications are discussed.

A controlled trial of cognitive behavioral treatment of panic in alcoholic inpatients with comorbid panic disorder.

Patients entering a 4-week inpatient alcoholism treatment program were screened for anxiety symptoms. Those with panic disorder with or without agoraphobia were randomly assigned to two groups. The treatment group received 12 hours of cognitive-behavioral treatment (CBT) for panic disorder in addition to the regular alcoholism treatment program: the control group received the regular program. Dropouts from the treatment group were also followed. Problem drinking and anxiety symptoms were measured at the start of the study, and at 3, 6, and 12 months posttreatment. Abstinence from drinking, and anxiety and mood symptoms improved after treatment in all of the groups; there were few differences in outcome between the groups. We concluded that this particular intervention had not been more effective than the regular alcohol treatment program in reducing problem drinking in those with panic disorder.