Panel urges treatment for panic disorder.

Effective treatments, both psychological and pharmaceutical, exist for panic disorder, a condition that strikes about one in 75 people at some time in their lives. Unfortunately, no systematic studies exist to guide physicians and mental health clinicians to the best form of treatment for specific cases of panic disorder, concludes a report issued last week by a panel of psychiatrists and psychologists convened by the National Institutes of Health in Bethesda, Md.

Panic disorder involves recurring panic attacks, 10- to 15-minute episodes in which an overwhelming fear of imminent death, going insane or loss of control takes over. Physical symptoms such as shortness of breath, dizziness, racing heart, nausea and chest pain often accompany the attacks. Panic disorder sufferers often experience the episodes of terror at random moments, although they frequently occur in association with stressful events, such as surgery, pregnancy and heavy caffeine intake.

At least one in three panic disorder sufferers develops agoraphobia, a fear of places or situations that they feel might trigger a panic attack or, in the event of an attack, hinder their escape or the delivery of help. Severe agoraphobics rarely venture from their homes.

Some psychoactive medications ease panic symptoms, the NIH panel asserts. These include two classes of antidepressants -- tricyclics and monoamine oxidase inhibitors -- and three tranquilizers classed as benzodiazepines. Cognitive-behavioral therapy -- designed to change mistaken beliefs about normal physiological reactions when anxious and provide gradual, supportive exposure to feared situations -- also serves as an effective treatment, the panel adds.

"To some degree, these have been dueling therapies," says panel chairman Layton McCurdy, a psychiatrist at the Medical University of South Carolina in Charleston. Psychiatrists generally emphasize drug treatment for panic disorder and believe the repeated attacks stem from an imbalance of specific chemical messengers in the brain, McCurdy notes; psychologists stress cognitive-behavioral approaches and argue that panic disorder results from misinterpretations of bodily responses to normal anxiety.

As a result, panel members could find no studies comparing the two categories of panic disorder treatments or charting their combined use. The first such investigation, now underway at four universities and directed by psychologist David H. Barlow of the State University of New York at Albany, remains in its early stages.

However, a return of panic symptoms apparently occurs much less often after cognitive-behavioral therapy, compared with drug treatment, McCurdy remarks.

For now, the panel recommends that clinicians reassess using any treatment that fails to reduce panic symptoms within eight weeks.

Although the report takes a "balanced and judicious" stand, panic disorder still evokes considerable controversy, says psychiatrist Gerald L. Klerman of Cornell University Medical College in New York City. Klerman did not sit on the NIH panel, but he notes that debate centers on whether panic disorder represents a diagnosis distinct from more general forms of anxiety, concerns over the addictive potential of benzodiazepines and questions about the actual efficacy of psychological treatments.