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Online Essay Club No.30: Panic

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Q: In a patient with panic disorder, discuss how you would arrive at a treatment choice of pharmacotherapy, psychological therapy, or both, with reference to knowledge of aetiology and outcome factors.

(Spring 1999 paper)

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Here is the advice given to examiners for marking this question:

CONTENT

The candidate must be able to describe biological theories of causation, psychological theories of causation, and treatment strategies.

Biological Theory

This should include an exposition of the postulated relationship between serotonin and panic. The good candidate will also mention other systems which have also been implicated, including noradrenergic, cholecytokinin, adenosine, and benzodiazepine systems.

Psychological Theory

In the sphere of psychological theory the candidate must be able to explain the basis of cognitive and/ or cognitive behavioural therapy. The better candidates may be able to describe the catastrophic misinterpretation hypothesis.

Treatment Strategies

Drug treatments must be mentioned, including anti-depressants, particularly those acting upon serotonergic systems and short acting benzodiazepines. The advantages and disadvantages of these treatment strategies should be laid out, including particular problems such as benzodiazepine dependency, or, in respect of antidepressants, the effect of initial prescription which may give a possible increase in anxiety and which may, in turn, give rise to poor compliance.

In discussing psychological treatments, there must be a description of behavioural, cognitive behavioural, and cognitive methodologies. The particular focus of treatments for panic should include mention of applied relaxation, respiratory control, interoceptive exposure and cognitive therapy.

LOGIC OF ARGUMENT

In discussing the case for an individual patient, the candidate may mention multi-centre trials, such as the CNCP study but, essentially, should be able to present an argument for and against pharmacological or psychological therapy for an individual patient depending upon that patient's circumstances and a precise assessment of the patient's need.

References

A number of key authors may be referred to including Nutt, McNally, Deaking, Klerman, Marks, Clark, Salkovskis, Beck, Cowan, and Tyrer.

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