[Treatment of panic disorders and agoraphobia. Psychotherapy, psychopharmacotherapy and their combination]

During the last two decades substantial progress has been achieved in the development and evaluation of effective treatment approaches to panic disorder and agoraphobia. Many clinical research studies in this area were begun after the definition of operationalized diagnostic criteria for panic disorder and agoraphobia in the DSM-III in 1980. Different concepts concerning the etiology, pathogenesis and maintaining factors of these disorders are still controversial. At the beginning of this controversy, psychopharmacological treatment was believed to suppress spontaneous panic attacks while behavioral treatment mainly focused on anticipatory fears and avoidance behavior. Meanwhile both treatment approaches have proved their effectiveness in reducing panic attacks and agoraphobia. Therefore, it was hypothesized that a combination of both individual treatments could enhance therapeutic efficacy. The few studies examining this question did not allow clear conclusions because of methodological shortcomings. In the short run, there seems to be a trend for better results with combined treatment. In the long run, however, combined therapy has not been observed to be superior to cognitive-behavioral therapy without any psychopharmacological support. In practice, adverse side effects restrict the application of psychopharmacological approaches. On the other hand, qualified cognitive-behavioral therapists are not always available, or patients are referred to them by general practitioners and psychiatrists after a delay. Criteria for the application of behavioral therapy, psychopharmacological therapy and their combination are proposed and discussed.