Panic Disorder Management

1. See also
   1. Panic Disorder
   2. Panic Disorder Diagnosis
   3. Agoraphobia
   4. Anxiety Disorder
   5. Anxiety Secondary Cause
   6. Anxiety Symptoms
   7. Generalized Anxiety Disorder
   8. Obsessive Compulsive Disorder
   9. Body Dysmorphic Disorder
   10. Social Anxiety Disorder (Social Phobia)
   11. Acute Stress Disorder
   12. Post-Traumatic Stress Disorder
   13. Excessive Worry
   14. Anxiety Non-pharmacologic Management
   15. Anxiety Pharmacologic Management
2. Management: Approach
   1. See Anxiety Non-pharmacologic Management
   2. Consider collaborative care with mental health referral
      1. Roy-Byrne (2001) Arch Gen Psychiatry 58:869-76 [PubMed]
   3. Avoid other provocative measures
      1. Avoid fluorescent lighting if sensitive
      2. Maximize sleep (avoid sleep deprivation)
      3. Avoid emotional conflict
      4. Avoid Alcohol (renders CBT ineffective)
         1. Often used by men to self-medicate
   4. Consider dietary Inositol 12 grams per day
   5. Treat Comorbid conditions
      1. Major Depression
      2. Generalized Anxiety Disorder
      3. Chemical Dependency (e.g. Alcohol Abuse)
3. Management: Cognitive-Behavioral Therapy (CBT)
   1. Protocol: Weekly Exercises over a 3 month period
      1. Therapist guided in 8-15 sessions (preferred)
      2. Workbook guided self-study (see resources below)
   2. Technique
      1. Recognize and reevaluate panic prodromal symptoms
      2. Respond by telling self you have nothing to fear
   3. Methods
      1. Relaxation before a Panic Attack occurs
         1. See Relaxation Training
         2. Consciously relax chest Muscles
      2. Distraction after onset of a Panic Attack
         1. Read or talk to a friend
      3. Controlled breathing for Hyperventilation
         1. Breath into a paper bag
      4. Exposure therapy (therapist guided)
         1. Patient increases exposure to feared situation
         2. May be most effective of CBT methods
      5. Other measures
         1. Diary
         2. Stress management
         3. Calm reassurance from others
   4. Resources
      1. Bourne (1995) Anxiety Phobia Workbook, New Harbinger
         1. Paid link to Amazon.com (ISBN 157224223X)
      2. Clum (1990) Coping with Panic, Brooks-Cole
4. Management: First-Line Effective Medications
   1. Background
      1. Antidepressants are effective in panic remission after 2 to 6 months of therapy (NNT 10)
      2. SSRI and SNRI are preferred over tricyclics and monotherapy with Benzodiazepines
   2. General pharmacologic therapy course
      1. Initial: 3 month trial (anticipate slow improvement)
      2. Maintenance: 6 to 12 months and longer
      3. Start medications at half of depression start dose
      4. Increase slowly (every 1-2 weeks)
   3. Selective Serotonin Reuptake Inhibitor (SSRI)
      1. Escitalopram (Lexapro)
      2. Citalopram (Celexa)
      3. Paroxetine (Paxil)
      4. Fluvoxamine (Luvox)
      5. Sertraline (Zoloft)
      6. Fluoxetine (Prozac)
   4. Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
      1. Venlafaxine (Effexor)
   5. Tricyclic Antidepressants (poor compliance)
      1. Imipramine (Tofranil)
         1. Effective and low cost ($8/month)
      2. Clomipramine (Anafranil)
      3. Nortriptyline (Pamelor)
      4. Desipramine (Norpramin)
5. Management: Second-Line Medications
   1. Benzodiazepines
      1. Precautions
         1. Limit use to severe cases
         2. Limit use to one month or less
         3. Longer acting agents are preferred (Clonazepam)
         4. Use minimum effective dose
         5. Use scheduled dosing (do not use as needed)
            1. Agents do not work quickly enough for prn use
         6. Avoid if history of Alcohol Abuse or Drug Abuse
         7. Avoid with cognitive-behavioral therapy (CBT)
            1. Renders CBT ineffective
      2. Agents
         1. Clonazepam (Klonopin) 0.25 to 0.5 mg PO qd to bid
            1. Preferred agent due to long Half-Life
         2. Alprazolam (Xanax): Risk of addiction
         3. Lorazepam (Ativan): Risk of addiction
      3. Consider combination protocol in severe, refractory cases
         1. Selective Serotonin Reuptake Inhibitor (SSRI) and
         2. Clonazepam 0.5 mg orally three times daily for 3 weeks then taper
         3. Goddard (2001) Arch Gen Psychiatry 58:681-6 [PubMed]
   2. Monoamine Oxidase Inhibitors (rare use in general practice)
      1. Phenelzine (Nardil)
      2. Tranylcypromine (Parnate)
   3. Adjunctive Medications (limited evidence)
      1. General
         1. Not effective as first-line monotherapy agents in Panic
         2. May be helpful when added to other agent listed above
      2. Agents
         1. Propranolol (Inderal)
         2. Clonidine
         3. Buspirone (Buspar)
         4. Bupropion (Wellbutrin)
6. Management: Moderate to severe recurrent episodes
   1. Precautions
      1. Protocol was taken from a psychiatrist's approach at conference
      2. Based only on expert opinion, with little evidence
   2. Start Benzodiazepine for 3 weeks and then wean
   3. Initiate long-term Anxiety Management
      1. Protocol 1: Concurrent Depression
         1. Selective Serotonin Reuptake Inhibitor (e.g. Paxil)
         2. Trazodone (Desyrel)
      2. Protocol 2
         1. Propranolol (Inderal)
         2. Imipramine
            1. Start: 10 mg orally daily
            2. Titrate: Increase in 25 mg increments q2-3 weeks
            3. Maximum: 150-200 mg daily
   4. Adjunctive steps for psychomotor symptoms
      1. Maximize SSRI dose
      2. Consider adding Remeron 7.5 mg bid
      3. Consider adding Neurontin 300 mg bid-tid
      4. Consider adding Hydroxyzine or Periactin
      5. Consider adding low dose Clonidine
      6. Consider adding low dose Risperdal (Risperidone)
7. References
   1. APA (2014) DSM 5, APA
   2. Starr (November, 1998) Patient Care
   3. DeGeorge (2022) Am Fam Physician 106(2): 157-64 [PubMed]
   4. Katerndahl (1997) Postgrad Med, 101(1): 147-66 [PubMed]
   5. Katerndahl (1996) J Fam Pract, 43(3): 275-82 [PubMed]
   6. Rubin (1996) Phys Sportsmed, 24(12):54-65 [PubMed]
   7. Saeed (1998) Am Fam Physician, 57(10):2405-12 [PubMed]
   8. Weinstein (1995) Am Fam Physician, 52(7):2055-63 [PubMed]
   9. Zamorski (2002) Am Fam Physician 66(8):1477-84 [PubMed]