Panic Disorder Treatment & Management

Patients with chest pain, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position; monitor the patients with pulse oximetry, ECG, and frequent determination of vital signs (including one set of orthostatic vital signs, when possible).

Patients with panic disorder may require frequent reassurance and explanation. Many may benefit from social service intervention.

A major component of therapy involves educating the patient that the symptoms are neither from a serious medical condition nor from a mental deficiency but rather from a chemical imbalance in the fight or flight response. This alone may account for the significant placebo response rate noted in clinical trials.^[34]

The emergency department staff must listen effectively and remain empathic and nonargumentative. Statements made by healthcare staff, such as, "It's nothing serious" and "It's related to stress," are frequently misinterpreted as implying lack of understanding and concern.

Intravenous medication (eg, lorazepam at 0.5 mg IV q20min) may be necessary in patients with panic disorder who, as a result of subsequent poor impulse control, pose a risk to themselves or to those around them.

Patients with panic disorder are probably best served by referral to a psychiatrist before beginning anxiolytic medications, because the psychiatrist can establish a constructive rapport with them and follow their needs on a long-term basis.

Institution of treatment for panic disorder in the emergency department is appropriate in a very limited subset of patients with panic disorder who are very motivated and cooperative, who possess an understanding of the psychological nature of their disorder, and whose symptomatology is elicited as a response to a temporary stress.

In such cases, pharmacotherapy with an oral benzodiazepine for a brief duration (approximately 1 wk) may be appropriate.

All patients with panic disorder should be referred to a psychiatrist, psychologist, or other mental health professional. Psychiatric treatment has a demonstrated effect on decreasing medical costs associated with emergency department and nonpsychiatric outpatient care.^[32] Free information is available to patients and physicians from the National Institute of Mental Health (NIMH).

Go to Anxiety Disorders; Anxiety Disorder, Specific Phobia; Anxiety Disorder, Separation Anxiety and School Refusal; and Phobic Disorders for more complete information on these topics.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT), with or without pharmacotherapy, is the treatment of choice for panic disorder, and it should be considered for all patients.^[33] CBT has higher efficacy and lower cost, dropout rates, and relapse rates than do pharmacologic treatments.

Pharmacologic care

Providing a few doses of a benzodiazepine as needed (prn) can enhance patient confidence and compliance. Total tablet dispensing should remain limited to ensure that patients understand that they have a limited supply of the drug and that this medicine represents a temporary or emergency use option.

The patient should be made to understand the importance of longer-term management with SSRI medication and psychotherapeutic techniques (eg, CBT).

Avoid the prescription of benzodiazepine in patients with a known history of substance misuse or alcoholism.

Follow-up care and referrals

Initial follow-up care should occur within 2 weeks, because SSRIs can cause an initial exacerbation of panic symptoms. For this reason, begin with the lowest dose with the understanding that the dose must be increased at the initial follow-up visit.

Assess potential suicide risk at all appointments. Ensure continuing treatment of any concurrent substance use disorders.

Follow-up care by a chemical dependence treatment specialist is recommended when indicated.

Patients with ventricular dysrhythmias, abnormal findings on ECG, abnormal findings on cardiac examination, or significant risk factors for heart disease should be referred to a cardiologist.^[23]

Inpatient care

Inpatient care is rarely considered for uncomplicated panic disorder. Patients may get admitted if they display any evidence of dangerous behavior, safety concerns, report suicidal or homicidal ideation as may occur in context of acute anxiety, fear of anxiety or its consequences.

Patients may require hospitalization for intoxication or withdrawal from sedative/hypnotics such as alcohol or Xanax, which sometimes get ingested or abused in attempts to medicate or manage the anxiety. Patients may also get hospitalized if they become so incapacitated by their anxiety that they are unable to adhere to outpatient care.

Inpatient treatment is necessary in patients with suicidal ideation and plan or with serious alcohol or sedative withdrawal symptoms, or when the differential includes other medical disorders that warrant admission (eg, unstable angina, acute myocardial ischemia).

Transfer

Transfer to an acute psychiatric facility may be necessary for suicidal or homicidal patients.

Supplemental oxygen and cardiac monitoring are recommended for patients experiencing dyspnea or chest pain.

Pharmacotherapy, cognitive and behavioral psychotherapy, and other psychological treatment modalities are used to treat panic disorder.

SSRIs are generally used as first-line pharmacologic agents in panic disorder, followed remotely by tricyclics. (Prior to the use of SSRIs for panic disorder, the tricyclics and the monoamine oxidase inhibitors [MAOIs] were used much more commonly for this condition.)

Benzodiazepines can achieve long-term control but should be reserved for patients with refractory panic disorder and should generate a psychiatric referral for pharmacologic management review and potentially a psychotherapist for any additional nonpharmacologic treatment options.

Fluoxetine (Prozac) can be used (especially if panic disorder occurs with depression); however, patients may poorly tolerate it initially, because the drug may initially increase anxiety, except at very low starting doses. Fluoxetine has a long half-life, making it a good choice in marginally compliant patients.

Mirtazapine (Remeron)^[35] has a much more sedating effect, generally reducing its potential to aggravate initial anxiety. Remeron acts distinctly as an alpha-2 antagonist, consequently increasing synaptic norepinephrine and serotonin, while also blocking some postsynaptic serotonergic receptors that conceptually mediate excessive anxiety when stimulated with serotonin.

Remeron may cause residual morning sedation that often improves with continued therapy and may cause an increase in appetite or weight gain.

Sedating antidepressants, such as Paxil, Remeron, and TCAs, are usually prescribed for use only at night before bed to help improve sleep, but they should include a warning for the patient not to operate a motor vehicle or machinery if he or she is feeling sedated or directly after the dose.

Prozac alters metabolism of cytochrome P-450 2D6-cleared agents; this fact should be considered. Paxil (paroxetine) represents a partially sedating SSRI option that is also available in a controlled release preparation (Paxil CR), which may improve tolerability, but Paxil still inhibits P450 2D6.

Citalopram (Celexa) and escitalopram (Lexapro) are likely to cause fewer hepatic enzyme interactions and may be appropriate initial choices for patients with complicated medical regimens or for those who are concerned about drug interactions.

Escitalopram also appears particularly well tolerated in preliminary studies, although it may be restricted from some formularies due to the large difference in cost with Celexa without a commensurate improvement in efficacy or tolerability for many patients.

Sertraline (Zoloft) represents a similar SSRI option with a slightly different pharmacodynamic profile, including sigma-receptor effects, although it has some P450 3A4 interactions.

Benzodiazepines act quickly but carry the liability of physiologic and psychologic dependence. Benzodiazepines can be reasonably used as an initial adjunct while SSRIs are titrated to an effective dose. Benzodiazepines then can be tapered over 4-12 weeks while the SSRI is continued. This approach can improve short-term tolerability, although it may increase the risk of sedation and requires warnings not to operate motor vehicles after taking benzodiazepines or if feeling sedated.

Alprazolam (Xanax) has been widely used for panic disorder, but it is currently discouraged because of its higher dependence potential; Xanax has a short half-life, which makes it particularly prone to rebound anxiety and psychological dependence. Clonazepam (Klonopin) has become a favored replacement, because it has a longer half-life and empirically elicits fewer withdrawal reactions upon discontinuation.

Most patients are started on long-term (eg, 6 mo) therapy with SSRIs, TCAs, or MAOIs only after consultation with their primary physician or psychiatrist.

Complications of benzodiazepine use

Because panic disorder is usually a chronic disorder, sole reliance on habituating drugs is discouraged.

Benzodiazepine dependence can occur in 30% of patients who are on therapy that lasts longer than 8 weeks.^[30] It is less likely to occur in patients without a history of chemical or emotional dependence. Benzodiazepine abuse is suggested by escalating dose consumption over time.

Benzodiazepine withdrawal can precipitate panic. The primary physician should gradually taper doses over several weeks or months.

Alternative drug therapies

Patients with panic disorder are twice as likely as the population to use alternative therapies. The use of dietary supplements (eg, herbs) should be discussed to avoid drug interactions.

Cognitive and behavioral psychotherapy can be used alone or in addition to pharmacotherapy. However, the combination approach yields superior results for most patients, compared with results from the use of either modality alone.^{[33, 36]}

Cognitive therapy helps patients to understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and how they can lead to secondary behavioral consequences.

Cognitive restructuring involves substituting positive thoughts (eg, patients can tell themselves that they are only feeling a little uneasiness or that their feelings will soon be gone) for the maladaptive thoughts that accompany panic (eg, feeling that they are going to die or are having a heart attack).

Specific patterns of cognitive distortions (twisted thoughts) tend to respond best to specific techniques described in CBT books (eg, The Feeling Good Handbook by David Burns, MD). While intended for use in conjunction with therapy, patients can purchase these books and complete the course themselves.

Behavioral therapy involves sequentially greater exposure of the patient to anxiety-provoking stimuli; over time, the patient becomes desensitized to the experience. Relaxation techniques also help to control patients' levels of anxiety.^{[37, 38]}

Respiratory training can help patients to control hyperventilation during panic attacks and to control anxiety with controlled breathing. Capnometry feedback-assisted breathing training can be used to prevent hypocapnia and stabilize the respiratory rate.

Interoceptive exposure involves encouraging patients to induce internal sensations (eg, dizziness, increased heart rate, lightheadedness) by spinning, exercising, or rapid breathing and to interpret these as normal bodily sensations.

Guided imagery and hypnotic suggestion may also be beneficial.

CBT is most effective when started early after symptom onset and is also most effective in patients with few psychological comorbidities.^[38]

Instructions for finding a cognitive behavioral therapist can be found at Paniccure.com.

Other forms of psychological treatment, including psychodynamic psychotherapy for specific issues, are available, but they exceed the scope of this article.

CBT with cognitive restructuring, relaxation techniques, breathing exercises, hypnotic suggestion, and interoceptive exposure may prevent recurrence.

Pharmacotherapy and dietary modification (eg, 5-hydroxytryptophan or inositol^[38] supplementation) also may prevent recurrence, as may exercise.^[39]

A study suggests that patients who give a high importance to religion and religious practices have improved panic symptoms and fewer recurrences.^[40]

Internet-based CBT and virtual reality exposure therapy are promising possibilities for recurrence prevention.^[41]

Patients with panic disorder are reluctant to believe their symptoms are not life threatening and have a high rate of emergency department use if education, treatment, and follow-up care are incomplete.

Moreover, because of a reluctance to use medications (related to a fear of losing control), patients with panic disorder are frequently noncompliant. Patients with panic disorder also have a 4-fold increase in the risk of adverse medication effects.

Consult a cardiologist for patients with abnormal ECG findings, ventricular dysrhythmia, abnormal cardiac examination, or risk factors for ischemic heart disease.^[26]

Consult a chemical dependence treatment specialist in cases of significant intoxication or withdrawal.

Refer all patients with panic disorder for psychiatric or mental health follow-up care and to support groups.