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Dr Marks acknowledged that a substantial proportion of his agoraphobic patients, following improvement during exposure treatment, still had active panic disorder. Although his scale defined what proportion of the patients no longer had any spontaneous panic attacks, he did not reply to Dr Grunhaus' request for this information.Dr Marks asserted that the handicap in agoraphobia is due to phobic avoidance; however, these patients also complain bitterly about their panic attacks, crave relief, and experience exacerbations of their avoidant patterns with recurrent panic attacks. The idea that the first priority is to remove behaviorally the avoidant patterns seems misguided to us, since the panic attacks can be regularly and entirely alleviated by appropriate pharmacologic intervention. The addition of imipramine in our studies markedly improved behavioral treatment. Dr Marks' treatment strategy depends on his belief that pharmacologic interventions with spontaneous panic attacks are useless.Each practitioner should decide the weight of
Klein DF. Panic Attacks in Phobia Treatment Studies-Reply. Arch Gen Psychiatry. 1983;40(10):1151-1152. doi:10.1001/archpsyc.1983.01790090113024