Treating Panic Disorder with Comorbidities: Why Focusing on the Panic May Be the Best Option
A common reason psychotherapists give for ignoring research is: “Research studies usually focus on one problem—the people I see often have multiple problems.” Whether this is reason enough to abandon evidence-based practice is debatable. The statement, however, does touch upon a very real concern: how do we choose a treatment focus for clients with multiple problems? The answer to this question isn’t always clear, but it is the responsibility of practitioners to see whether there is research that can guide a decision. In the case of panic disorder, research suggests clients will get the most bang for their buck by focusing on the panic.
A Little About the Study
It’s not a new study—it was published in 2007—but I thought it was really interesting when I originally read it and haven’t had a chance to write about it yet. The first author is Dr. Michelle Craske, a professor at UCLA, and one of the most renowned anxiety researchers.
In this study, sixty-five people with panic disorder were randomly assigned to one of two groups. Everyone in the study received 12 weekly sessions of a manualized group cognitive behavioral treatment for panic disorder as well as 6 adjunct individual sessions spaced every two weeks. For half the participants, the individual sessions reinforced what was taught in the panic disorder group; for the other half, the individual session provided tailored cognitive behavioral treatment for a co-occurring disorder. The most common co-occurring conditions were major depressive disorder, generalized anxiety disorder, social anxiety, and specific phobia.
The individual sessions were scheduled every two weeks in order to simulate therapist “straying” from treating one condition to another. For example, someone with comorbid depression in the experimental group would receive cognitive behavior therapy for depression in the individual group, whereas someone in the control group would receive additional panic disorder treatment in the individual group. As a consequence, the control group only received panic disorder treatment regardless of comorbidities, and the experimental group received panic disorder treatment and individual sessions targeting a specific comorbidity.
The researchers assessed participants before treatment, post-treatment, and at 6- and 12-months following treatment.
“More of the Same” Wins Out
The results are by no means a slam dunk, but they suggest that people who only received panic disorder treatment did better—both for panic and the comorbid condition—than people who were treated for panic and a comorbid problem. Some of the effects were small, and superiority for panic treatment-only wasn’t across the board; however, the results suggest that not only can focusing on panic disorder result in improvements in comorbid conditions even if the co-morbid conditions aren’t directly addressed, but that it may be a better option than trying to address both. As the authors put it, “the results raise the interesting possibility that staying focused is superior to straying” (p. 1106).
Take Home Message
For therapists who are skeptical that conclusions drawn from research studies are applicable in their own work, this study probably didn’t win anyone over. The attempt at mimicking how an actual therapist would deal with comorbid conditions—devoting a session to it every two weeks—is a little contrived (although very creative!). I can see how someone might dismiss this single study.
My take? Given that panic disorder is one of the most treatable conditions in the research literature, I think this study offers some compelling evidence for treating the panic first. Once clients have learned to manage their panic, other problems may resolve on their own. If any problems remain after successful resolution of panic, then these problems may then be addressed. In a nutshell: for people with panic disorder and co-occurring conditions, it’s probably best to treat the panic first.