Observations on the cognitive behavioral treatment of panic disorder: Impact of benzodiazepines

Multi-modal treatment using CBT plus benzodiazepines is a common approach for PD. A survey of two anxiety disorder clinics revealed that approximately one-half of all PD patients receive combined treatment (usually CBT plus alprazolam). In fact, this strategy is the recommended treatment of choice, according to several recent publications. The rationale for such a treatment is that benzodiazepines help to decrease anxiety and panic in the short run, making the patient amenable to psychotherapy, while CBT offers a long-term solution for coping with panic. Despite this line of reasoning, in our clinical experience, we find that the concomitant use of benzodiazepines throughout the course of CBT has an adverse effect on the psychotherapy. Benzodiazepines interfere with the basic mechanism of action of CBT. For CBT to be effective, anxiety must be elicited under the controlled circumstances of the therapy. It is only through the evocation of anxiety that useful coping skills may be established. Unfortunately, benzodiazepines prevent the evocation of anxiety during treatment, and there is less opportunity to develop effective coping skills. Moreover, anxiolytic effects are then attributed to the medication and not to psychotherapeutic growth which will remain with the patient after the medication has been discontinued.