Treating Medication-Resistant Panic Disorder: Predictors and Outcome of Cognitive-Behavior Therapy in a Brazilian Public Hospital

Abstract

Background: In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy. Methods: Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response. Results: Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05). Conclusion: Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.

Predictors of relapse in the second follow-up year post cognitive-behavior therapy for panic disorder

“…17 Stress also appears to increase the probability of relapse after the discontinuation of serotonergic antidepressants 18 and a great deal of evidence indicates that fear of anxiety symptoms plays a role in the etiology and maintenance of PD. 19 The efficacy of CBT in group for PD has been described in previous studies, showing moderate to high effect size considering the different outcome measurements, after acute treatment 20 and in one year follow-up. 21 In the present study, we investigated predictors of relapse two years after a brief cognitive-behavior group therapy (CBGT) in patients who had failed to respond to pharmacologic treatment.…”

Terapia cognitivo-comportamental no transtorno de pânico

“…In conclusion, CBT is an efficacious treatment modality for PD patients, whether as first-line therapy 17 or as a strategy for patients who do not respond to medication, 26,30,33 or even, as a combined treatment with drug therapy, as seen before. 32 This treatment presupposes correction of automatic catastrophic thoughts that worsen anxiety symptoms and fear, anticipatory anxiety, and predispose to avoidances.…”

“…[27][28][29] CBT can be introduced at any stage of treatment, ranging from primary prevention to interventions to individuals refractory to other treatments. 17 It can be started concomitantly with medications 17,18,30 and uses the following resources as techniques: psychoeducation, anxiety coping techniques (muscle relaxation and abdominal or diaphragmatic breathing), cognitive restructuring, interoceptive and gradual in vivo exposure. 17,24,25 Results of a study of 76 PD patients with or without agoraphobia have suggested that the combination of cognitive (psychoeducation, cognitive restructuring, problem solving techniques) and behavioral (interoceptive and in vivo exposure) techniques has significant efficacy in the improvement of acute symptom remission and in the maintenance of gains in the follow-up until 6 months after CBT.…”

“…36 As to benzodiazepines, 49% of patients were using it before CBT and only 22% still used the drug after a 1-year follow-up. 30 Because exposure assignments appear to enhance the efficacy of medication treatment, 47 we recommend that elements of CBT, particularly instruction in stepwise exposure, should be offered as part of medication treatment of PD. However, when state-of-theart CBT is available to patients, we believe this intervention can be offered alone and achieve results that rival combination treatment in many cases and offer the potential for greater durability of treatment and lower cost.…”

“…There is also evidence suggesting that patients who fail to respond to CBT for PD can achieve benefits from subsequent pharmacotherapy, and as we observed, there are a number of small studies indicating that nonresponders to medication treatment of PD can do well in CBT. 30,39 Novel combination treatment -D-cycloserine In the face of limitations on the benefit of traditional combined treatments (CBT plus antidepressants or benzodiazepines) for PD, there is promising evidence for a new strategy for combined treatment for the anxiety disorders. This strategy is focused on the promotion of better learning in therapy sessions, and grew out of basic research on the neural circuits underlying fear extinction.…”