CLINICAL REVIEW / PEER REVIEWED

Panic Disorder: Ensuring Prompt Recognition and Treatment

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TREATMENT INCLUDES CBT AND MEDICATION

PD is a chronic disease with a variable course, but the long-term prognosis is good. PD is usually treated in an outpatient setting. Consider hospitalization if the patient is suicidal, if the potential for life-threatening withdrawal symptoms is high (as with alcohol or benzodiazepines), or if the symptoms are severely debilitating or attempted outpatient treatment is unsuccessful. Pharmacologic and psychotherapeutic interventions are used for PD (see Figure), although there is not enough evidence to recommend one versus the other or combination therapy versus monotherapy.9

Treatment algorithm for panic disorder image

All Lacey’s test results come back negative, and the psychiatric assessment reveals that she meets the DSM-5 criteria for PD. Counting on the strength of their relationship, her PCP talks to her about PD and discusses treatment options, which include counseling, medication, or both. Lacey agrees to a referral for cognitive behavioral therapy (CBT) with a psychologist embedded at her primary care clinic and to begin taking medication. Her PCP starts her on sertraline 25 mg/d.

In CBT, Lacey’s psychologist teaches her about “fight or flight” and explains that it is a normal physiologic response that can lead to panic. Lacey learns to approach her physical symptoms in a different way, and how to breathe in a way that slows her panic reaction.

Consider SSRIs and SNRIs

Firstline medication is a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI), due to the better tolerability and lower adverse effect profile of these classes compared with the tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs). MAOIs are usually reserved for patients in whom multiple medication trials have failed.

Special considerations. American Psychiatric Association guidelines advise starting with a very low dose of an SSRI or SNRI, such as paroxetine 10 mg/d (although many clinicians start lower, at 5 mg/d), to avoid hypersensitivity reactions. Gradually titrate the dose upward within three to seven days of initiation, until a therapeutic dose is reached over two to six weeks. Schedule follow-up visits for every one to two weeks at the beginning of treatment and every two to four weeks until the therapeutic dose is reached. Assess safety/suicidality at each visit.

Keep in mind that the onset of therapeutic effect is between two and four weeks, but that clinical response can take eight to 12 weeks. Continue pharmacotherapy for at least one year. When discontinuing the medication, taper it slowly, and monitor the patient for withdrawal symptoms and recurrence of PD.9

Consider adding a benzodiazepine if symptoms are debilitating.9 Keep in mind, though, that the potential for addiction with these medications is high and they are intended to be used for only four to 12 weeks.8 Onset of action is within the first week, and a scheduled dosing regimen is preferred to giving the medication as needed. The starting dose (eg, clonazepam 0.25 mg bid) may be increased three to five days following initiation.9

Evidence supports the use of CBT for PD

CBT is an evidenced-based treatment for PD.10-13 Up to 75% of patients treated with CBT are panic free within four months.10 Other techniques proven effective are progressive muscle relaxation training, breathing retraining, psychoeducation, exposure, and imagery.14

Treatment with medications and CBT, either combined or used individually, is effective in 80% to 90% of cases.15 CBT has been shown to decrease the likelihood of relapse in the year following treatment.15 Good premorbid functioning and a brief duration of symptoms increase the likelihood of a good prognosis.15

WHEN TO REFER TO A PSYCHIATRIST

Consider referral to a psychiatrist when patients have a comorbid psychiatric condition that complicates the clinical picture (eg, substance abuse disorder), if the diagnosis is uncertain, or if the patient does not respond to one or two adequate trials of medication and psychotherapy. Although psychiatric follow-up is sometimes difficult due to a lack of psychiatrist availability locally, it is a best-practice recommendation.

Ten days after Lacey starts the sertraline 25 mg/d, she calls the PCP to report daily diarrhea. She stopped the sertraline on her own and is asking for another medication. She also expresses her frustration with the severity of the symptoms. She is having three to five panic attacks daily and has been missing many days of work.

On the day of her follow-up PCP appointment, Lacey also sees the psychologist. She reports that she’s been practicing relaxation breathing, tracking her panic attacks, limiting her caffeine intake, and exercising regularly. But the attacks are still occurring.

The PCP switches her to paroxetine 10 mg/d and, due to the severity of the symptoms, prescribes clonazepam 0.5 mg bid. Two weeks later, Lacey reports that she is feeling a little better, has returned to work, and is hopeful that she will be her “normal self again.” The PCP plans to encourage continuation of CBT, titrate the paroxetine to 20 to 40 mg/d based on symptoms, and slowly taper the clonazepam toward discontinuation in the near future.

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