Attempts to understand the underlying etiology of panic disorder have, at times, oscillated between reductionistic biologic or psychologic characterizations that have put pharmacotherapists and cognitive-behavioral therapists on opposite sides of a fence with patients caught in the middle. However, research emerging over the last couple of decades is pointing to a more complex interplay between dysregulated neurobiological systems and psychological factors that influence the manifestations of fear and anxiety and permit a more nuanced view of the etiology of panic disorder while pointing to potential rational strategies for treating patients. The articles in this supplement explore a range of explanatory models relevant to the underlying etiology of panic disorder, and then focus on treatment, including pharmacologic agents, and a paradigm in which cognitive-behavioral therapy (CBT) can be efficiently and effectively integrated with pharmacotherapy in an attempt to optimize patient care.

In the first article, David Baldwin, MB, BS, DM, FRCPsych, discusses the burden of panic disorder to patients and society; the difficulties associated with misdiagnosis and inadequate treatment; the challenges imposed by excess healthcare utilization, reduced quality of life, and psychiatric and medical comorbidity; and the implications for therapeutics.

Panic disorder (PD) is typically a distressing, chronic, and recurrent mental disorder associated with a high rate of comorbidity with other mood, anxiety, and substance abuse disorders, increased risk of medical morbidity and mortality, and marked impairment of functioning and reduced quality of life. Most patients with PD first seek treatment in emergency room or general practice settings. In the overwhelming majority of cases, PD patients present with primarily somatic symptoms, many of which are common to medical illnesses. It is, therefore, not surprising that PD is often misdiagnosed and that patients with this disorder often spend years seeking treatment and undergoing costly and unnecessary tests and medical consultations before receiving a correct diagnosis. Better diagnosis and treatment of PD to achieve remission and prevent relapse has the potential to reduce the burden of this illness to the individual and society.

Panic disorder (PD) is a complex, multidimensional psychiatric disorder characterized by the presence of panic attacks as well as anticipatory anxiety and panic-related phobias (eg, agoraphobia). Although the etiology of this disabling disorder remains unclear, advances in basic neuroscience and in imaging studies have led to a greater understanding of the neurocircuitry and neurochemistry that are involved in modulating fear and anxiety and that are relevant to understanding PD. A preliminary integrated model can be outlined, but there is a need for additional research that cuts across genetic investigation, provocation studies, neuroimaging techniques, and treatment trials. As research continues and greater insight into the mechanisms underlying PD is achieved, additional treatment strategies may emerge.

Panic disorder, frequently complicated by agoraphobia in the clinical setting, is a relatively common disorder that is associated with significant morbid burden and dysfunction in affected individuals. PD treatment is focused on the reduction of panic attacks, avoidance behavior, and anticipatory anxiety, as well as the resolution of comorbid conditions, with the goal of normalizing function and improving overall quality of life. Antidepressants, including the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, as well as benzodiazepines, are commonly used as primary pharmacotherapies for the treatment of PD, with a variety of other novel interventions potentially useful as well, to optimize treatment outcome.

Despite ample evidence of the efficacy of cognitive-behavioral therapy (CBT) for the treatment of patients with panic disorder (PD), dissemination of this evidence is proceeding slowly. This article highlights some of the issues surrounding the dissemination of CBT for PD and suggests strategies for integrating CBT with pharmacotherapy. Treatment principles, with attention to the modification of CBT protocols for use in a brief-contact format, are reviewed. The principles and application of exposure interventions are discussed for both in vivo (situational) and interoceptive (feared anxiety sensations) exposure, with emphasis on the learning of safety in the context of feared sensations of anxiety. Contextual factors that may affect the success of exposure interventions and cognitive and informational interventions are also discussed.