A certain type of cognitive-behavioral therapy (CBT) aimed at reducing the
anxiety associated with symptoms of panic disorder may also help to reduce the
severity of medication side effects, according to a study published in the
February American Journal of Psychiatry.
Patients treated with imipramine and "panic control therapy"
experienced less-severe fatigue, weakness, dry mouth, and sweating. As a
result, they tended to stick with the imipramine treatment longer than those
who received the medication alone.
According to lead author Sue Marcus, Ph.D., the goal of this type of CBT
used in the study aims to reduce "the fear of somatic sensations"
related to panic disorder while reducing the perceived severity of medication
side effects. In addition, CBT may help decrease the chances that a panic
episode may be mistaken for a medication side effect, she told Psychiatric
News. Marcus is an assistant professor of psychiatry and biomathematics
in the Department of Psychiatry at Mt. Sinai School of Medicine.
Panic control therapy is a 12-session treatment developed by David Barlow,
Ph.D., at Boston University. It includes patient education, breathing
retraining, cognitive restructuring, and "interoceptive
conditioning," in which patients engage repeatedly in activities that
bring about physiological changes such as breathlessness until they understand
that these sensations are not harmful.
During cognitive restructuring, patients are trained to avoid
catastrophizing normal physiological fluctuations and sensations such as
breathlessness or rapid heart-beat.
Researchers analyzed data on 172 patients who met criteria for panic
disorder and who were enrolled in a multisite study completed in 1998 at
anxiety research centers at Boston University, Hillside Division of Long
Island-Jewish Hospital, Yale University, and the University of Pittsburgh.
Patients in Marcus's study were randomly assigned to receive imipramine (83),
imipramine plus CBT (65), or placebo (24).
The study was divided into three treatment phases—a 12-week acute
phase during which subjects were seen 10 times for treatment, a six-month
maintenance phase in which subjects who responded to acute therapy were
maintained on treatment and seen once a month, and a six-month follow-up phase
during which treatments were discontinued and subjects were evaluated
Patients assigned to receive imipramine or placebo began the study by
receiving 25 mg daily and could go as high as 300 mg daily for the remainder
of the acute phase.
During each of the medication visits, patients were asked whether they were
experiencing side effects such as insomnia, sleep disturbance, drowsiness,
nervousness, fatigue, irritability, memory problems, impaired cognition,
dizziness, headache, or blurred vision.
During the study period, 18 patients dropped out due to side effects.
Thirteen patients dropped out during the acute-treatment phase: 11 of the 83
patients who received only imipramine and two of the 65 patients who received
imipramine plus CBT. The other five dropped out during the maintenance phase.
No patients in the placebo group dropped out.
Marcus found that patients treated with imipramine plus CBT reported
overall less fatigue or weakness, dry mouth, and sweating during the three
study phases compared with those who received imipramine alone (see
FIG1). The difference was
The placebo group reported greater levels of excitement and nervousness,
irritability, headache, and libido decrease compared with the other two
groups, which researchers attributed to symptoms of their panic disorder.
Marcus pointed out that given reduced side-effect severity and dropout
rates among those who received panic control therapy plus imipramine, combined
treatment may in fact be superior for panic-disorder patients.
She acknowledged that her findings are limited by the study's small sample
size and need to be confirmed through studies with larger samples. Studies
measuring the effect of CBT on patients who are taking medications other than
imipramine may also be helpful, she added.
The National Institute of Mental Health funded the study.
The results of "A Comparison of Medication Side-Effect Reports
by Panic Disorder Patients With and Without Concomitant Cognitive-Behavior
Therapy" is posted at<http://ap.psychiatryonline.org/cgi/collection/cognitive_therapy?notjournal=ap>.▪