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Panic Disorder Management
Aka: Panic Disorder Management, Panic Management
- See also
- Panic Disorder
- Panic Disorder Diagnosis
- Agoraphobia
- Anxiety Disorder
- Anxiety Secondary Cause
- Anxiety Symptoms
- Generalized Anxiety Disorder
- Obsessive Compulsive Disorder
- Body Dysmorphic Disorder
- Social Anxiety Disorder (Social Phobia)
- Acute Stress Disorder
- Post-Traumatic Stress Disorder
- Excessive Worry
- Anxiety Non-pharmacologic Management
- Anxiety Pharmacologic Management
- Management: Approach
- See Anxiety Non-pharmacologic Management
- Consider collaborative care with mental health referral
- Roy-Byrne (2001) Arch Gen Psychiatry 58:869-76 [PubMed]
- Avoid other provocative measures
- Avoid fluorescent lighting if sensitive
- Maximize sleep (avoid sleep deprivation)
- Avoid emotional conflict
- Avoid Alcohol (renders CBT ineffective)
- Often used by men to self-medicate
- Consider dietary Inositol 12 grams per day
- Treat Comorbid conditions
- Major Depression
- Generalized Anxiety Disorder
- Chemical Dependency (e.g. Alcohol Abuse)
- Management: Cognitive-Behavioral Therapy (CBT)
- Protocol: Weekly Exercises over a 3 month period
- Therapist guided in 8-15 sessions (preferred)
- Workbook guided self-study (see resources below)
- Technique
- Recognize and reevaluate panic prodromal symptoms
- Respond by telling self you have nothing to fear
- Methods
- Relaxation before a Panic Attack occurs
- See Relaxation Training
- Consciously relax chest Muscles
- Distraction after onset of a Panic Attack
- Read or talk to a friend
- Controlled breathing for Hyperventilation
- Breath into a paper bag
- Exposure therapy (therapist guided)
- Patient increases exposure to feared situation
- May be most effective of CBT methods
- Other measures
- Diary
- Stress management
- Calm reassurance from others
- Resources
- Bourne (1995) Anxiety Phobia Workbook, New Harbinger
- Paid link to Amazon.com (ISBN 157224223X)
- Clum (1990) Coping with Panic, Brooks-Cole
- Management: First-Line Effective Medications
- General pharmacologic therapy course
- Initial: 3 month trial (anticipate slow improvement)
- Maintenance: 6 to 12 months and longer
- Start medications at half of depression start dose
- Increase slowly (every 1-2 weeks)
- Consider combination protocol in severe cases
- Selective Serotonin Reuptake Inhibitor (SSRI) and
- Clonazepam 0.5 mg PO tid for 3 weeks then taper
- Goddard (2001) Arch Gen Psychiatry 58:681-6 [PubMed]
- Selective Serotonin Reuptake Inhibitor (SSRI)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Fluoxetine (Prozac)
- Tricyclic Antidepressants (poor compliance)
- Imipramine (Tofranil)
- Effective and low cost ($8/month)
- Clomipramine (Anafranil)
- Nortriptyline (Pamelor)
- Desipramine (Norpramin)
- Management: Second-Line Medications
- Benzodiazepines
- Precautions
- Limit use to severe cases
- Limit use to one month or less
- Longer acting agents are preferred (Clonazepam)
- Use minimum effective dose
- Use scheduled dosing (do not use as needed)
- Agents do not work quickly enough for prn use
- Avoid if history of Alcohol Abuse or Drug Abuse
- Avoid with cognitive-behavioral therapy (CBT)
- Renders CBT ineffective
- Agents
- Clonazepam (Klonopin) 0.25 to 0.5 mg PO qd to bid
- Preferred agent due to long half-life
- Alprazolam (Xanax): Risk of addiction
- Lorazepam (Ativan): Risk of addiction
- Monoamine Oxidase Inhibitors
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Adjunctive Medications
- General
- Not effective as first-line agents in Panic
- Helpful when added to other agent listed above
- Agents
- Propranolol (Inderal)
- Clonidine
- Buspirone (Buspar)
- Bupropion (Wellbutrin)
- Management: Moderate to severe recurrent episodes
- Start Benzodiazepine for 3 weeks and then wean
- Initiate long-term Anxiety Management
- Protocol 1: Concurrent Depression
- Selective Serotonin Reuptake Inhibitor (e.g. Paxil)
- Trazodone (Desyrel)
- Protocol 2
- Propranolol (Inderal)
- Imipramine
- Start: 10 mg qd
- Titrate: Increase in 25 mg increments q2-3 weeks
- Maximum: 150-200 mg qd
- Adjunctive steps for psychomotor symptoms
- Maximize SSRI dose
- Consider adding Remeron 7.5 mg bid
- Consider adding Neurontin 300 mg bid-tid
- Consider adding Hydroxyzine or Periactin
- Consider adding low dose Clonidine
- Consider adding low dose Risperdal (Risperidone)
- References
- APA (1994) DSM IV, APA, p. 395
- Starr (November, 1998) Patient Care
- Katerndahl (1997) Postgrad Med, 101(1): 147-66 [PubMed]
- Katerndahl (1996) J Fam Pract, 43(3): 275-82 [PubMed]
- Rubin (1996) Phys Sportsmed, 24(12):54-65 [PubMed]
- Saeed (1998) Am Fam Physician, 57(10):2405-12 [PubMed]
- Weinstein (1995) Am Fam Physician, 52(7):2055-63 [PubMed]
- Zamorski (2002) Am Fam Physician 66(8):1477-84 [PubMed]