288 TREATMENT OF SPECIFIC ANXIETY DISORDERS
hood physical or sexual abuse, and individuals with comorbid panic and PTSD were
significantly more likely to have survived rape (43%) than those with panic alone (7.5%)
(Leskin & Sheikh, 2002). These findings indicate that lifetime trauma may act as a risk
factor for panic disorder, especially in women. Moreover, social environmental factors
may also affect clinical course, with factors such as childhood separation, lower socio-
economic status, and marital breakup significant predictors of poor outcome 7 years
after initial treatment (Noyes et al., 1993).
Relationship problems may be more common in panic disorder than in other con-
ditions, both as a contributing cause and a consequence of the disorder (Marcaurelle,
Bélanger, & Marchand, 2003). However, the empirical evidence is inconsistent in
whether panic disorder with agoraphobia is associated with more marital problems and
quality of marital relationship at pretreatment is not a significant predictor of treatment
prognosis (Marcaurelle et al. 2003).
If left untreated, panic disorder typically takes a chronic course with only 12% of
patients achieving complete remission after 5 years (Faravelli, Paterniti, & Scarpato,
1995). In a 1-year prospective study Ehlers (1995) found that 92% of panic patients con-
tinued to experience panic attacks and 41% of the initially remitted patients relapsed.
However, in an 11-year follow-up of 24 patients with panic disorder treated in an 8-week
clinical trial of imipramine, alprazolam, or placebo, 68% had no panic attacks over the
follow-up period and 90% showed no or only mild disabilities (Swoboda et al., 2003).
This suggests that with treatment, the long-term prognosis for panic disorder may be
more optimistic.
Panic disorder is also associated with significant functional impairment and decre-
ments in quality of life, especially when comorbid with depression (Massion, Warshaw,
& Keller, 1993; Roy-Byrne et al., 2000; Sherbourne et al., 1996). Furthermore, greater
functional impairment can significantly increase the likelihood of panic recurrence in
previously recovered individuals (Rodriguez, Bruce, Pagano, & Keller, 2005). In a meta-
analytic review of 23 quality of life studies, panic disorder was similar to the other anxi-
ety disorders in showing significant decrements in physical health, mental health, work,
social functioning, and family functioning (Olatunji et al., 2007), although poor subjec-
tive quality of life is worse in major depression than in panic disorder (Hansson, 2002).
Panic disorder with agoraphobia can be a costly disorder both in terms of human
suffering and increased burden on health care services (e.g., Eaton et al., 1991). In the
NCS-R panic disorder and PTSD had the highest annual rates of mental health utiliza-
tion compared to the other anxiety disorders, and panic disorder had a much higher rate
of accessing general medical care (Wang, Lane, et al., 2005; see also Deacon, Lickel,
& Abramowitz, 2008). The health care costs associated with panic disorder, then, are
substantial. The number of annual medical visits by individuals with panic disorder is
seven times that of the general population, resulting in an annual medical cost that is
twice the American population average (Siegel, Jones, & Wilson, 1990).
Clinician Guideline 8.7
Negative life events, past and current stressors, negative coping style, and psychosocial
impairment will have a significant impact on the course of panic disorder. The clinician
must take these factors into consideration during assessment and treatment of panic.