Etiology and treatment of panic disorders

At this point in time, what do we know concerning the etiology and treatment of panic disorders? First, it appears that panic disorder is reached through multiple paths. Genetic vulnerability manifested through biological vulnerability appears to be a factor in at least some instances of this disorder. Environmental factors, such as interpersonal and other forms of stress, as well as various cognitive processing errors, also likely play a part in the development of panic. Whether these factors are additive or not or whether they combine in some other way to increase the probability that panic will develop is simply unknown at this time. A number of behavioral treatment techniques have developed within the past ten years as ways of ameliorating panic disorder. These techniques have been tied conceptually to etiological models of panic. In addition to exposure techniques, various physiologically based approaches (e.g., breathing retraining) and cognitively based approaches have been studied. These approaches target not only the avoidance behavior of agoraphobia, but also the panic attacks themselves. It appears safe to say that these techniques currently provide a viable alternative to pharmacological agents. Nonetheless, controlled studies that directly assess the relative merits of behavioral and pharmacological techniques are vitally needed. The present review uncovered a number of research questions and methodological issues. Unresolved etiological issues requiring clarification in the near future include the following: (1) Are stressful events important in the development of panic, or are they more incidentally related? Important in answering this question will be studies comparing panic disordered individuals with others suffering from such disorders as dysthymic reaction as well as other anxiety disorders. Also important will be longitudinal studies of individuals found to be suffering from panic disorder in order to determine whether exacerbations are stress related. (2) Are catastrophic thinking and other cognitive errors primary or secondary to panic disorder? That is, are such cognitive problems stable characteristics of panic disordered persons, or do they develop secondarily to panic disorders? (3) What determines whether an individual who develops panic disorder will also develop avoidance behavior? Along these same lines, will treatment approaches that successfully reduce panic have the secondary effect of reducing the prevalence of agoraphobia? (4) Are the behavioral techniques currently being developed to treat panic disorders viable with more severe types of agoraphobia, and will they add significantly to improvement rates when paired with exposure techniques?