eMedicine Specialties > Emergency Medicine > Psychosocial

Panic Disorders: Follow-up

Author: Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Contributor Information and Disclosures

Updated: May 7, 2009

Follow-up

Further Inpatient Care

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

Further Outpatient Care

  • 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.
  • All patients with PD should be referred to a psychiatrist, psychologist, or other mental health professional. Free information is available to patients and physicians from the National Institute of Mental Health (NIMH) by calling 1-800-64-PANIC or by writing to the following address: NIMH
    Room 7C-02
    5600 Fishers Ln
    Rockville, MD 20857
  • Cognitive behavioral therapy (CBT), with or without pharmacotherapy, is the treatment of choice, and it should be considered for all patients.19 CBT has higher efficacy and lower cost, dropout rates, and relapse rates than pharmacological treatments. CBT in combination with pharmacotherapy is more effective than either alone.20
    • Patients meet with therapists for 1-3 hours per week for at least 8-12 weeks.
    • 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).
    • Behavioral therapy involves various relaxation techniques and breathing retraining. Guided imagery and hypnotic suggestion may also be beneficial.
    • Capnometry feedback-assisted breathing training therapy 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.
    • Instructions for finding a cognitive behavioral therapist can be found at Paniccure.com.

Inpatient & Outpatient Medications

  • Although pharmacotherapy for panic disorder should generally be deferred to the follow-up psychiatrist, in a very limited subset of patients with panic disorder in the ED, alprazolam (Xanax) as an abortive and/or prophylactic agent may be instituted for a brief course of treatment (generally 1-3 days, recommend no longer than 1 wk)
  • 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.

Transfer

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

Deterrence/Prevention

  • 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 supplementation) may prevent recurrence.
  • Exercise is effective in preventing panic recurrence.
  • Patients who have give a high importance to religion and religious practices have improved panic symptoms and fewer recurrences.
  • Internet-based cognitive behavioral therapy and virtual reality exposure therapy are promising.

Complications

  • Patients with panic disorder are reluctant to believe their symptoms are not life threatening and have a high rate of ED use if education, treatment, and follow-up care are incomplete.
  • 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 increased risk of medication adverse effects.
  • Benzodiazepine abuse is rare. It is less likely to occur in patients without history of chemical dependence or emotional dependence.
    • Benzodiazepine abuse is suggested by escalating dose consumption over time.
    • Because panic disorder is usually a chronic disorder, sole reliance on habituating drugs (benzodiazepines) is discouraged.
    • Benzodiazepine dependence can occur in 30% of patients on long-term therapy longer than 8 weeks.
    • Benzodiazepine withdrawal can precipitate panic. The primary physician should gradually taper doses over several weeks or months.
  • Individuals with panic disorder have a suicide rate 18 times higher than the population.
  • The rate of substance abuse (especially stimulants, cocaine, and hallucinogens) in persons with panic disorder is 7-28%, a risk 4-14 times greater than that of the population.
  • Pregnant mothers with panic disorder are more likely to have infants of smaller birth weight for gestational age.
  • Panic patients are nearly twice as likely to develop coronary artery disease, and those with known coronary disease can experience myocardial ischemia during their panic episodes.21,22

Prognosis

  • Long-term prognosis is usually good, although the risk of coronary artery disease is nearly doubled. In patients with coronary disease, panic can induce myocardial ischemia.22 The risk of sudden death may also theoretically be increased due to reduced heart rate variability and increased QT interval variability.
  • Appropriate pharmacological therapy and cognitive-behavioral therapy, individually or in combination, are effective in more than 85% of cases.

Patient Education

  • Information regarding panic disorder and support groups can be obtained from the NIMH (see Further Outpatient Care).
  • Advise patients with panic disorder to avoid nicotine, sympathomimetic or anticholinergic drugs, caffeine, and alcohol.
  • Dietary modification (eg, 5-hydroxytryptophan or inositol supplementation) may be effective in preventing recurrence. Such herbal supplementation should be deferred until after the patient has discussed it with the psychiatrist or primary care provider that is responsible for the follow-up and long-term care of the patient.
  • For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center and Anxiety Center. Also, see eMedicine's patient education articles Panic Attacks, Anxiety, and Palpitations.

Miscellaneous

Medicolegal Pitfalls

  • Persons with panic disorder are no less likely (and perhaps even twice as likely) to have coronary artery disease than the general population.
  • Approximately 44% of ED patients with panic disorder have a history of coronary disease.
  • Exclude acute coronary syndromes in patients with risk factors, history, and ECG findings before labeling the event as panic.
  • Patients with supraventricular tachycardia have the potential to be misclassified as having panic disorder (in more 50% of cases), and panic disorder may be missed if event monitoring is not obtained.
  • As many as 10-20% of patients with panic disorder have had a suicide attempt.
  • As many as 7-28% of patients with panic disorder have a history of substance abuse.
  • Many of the symptoms of an anxiety attack correspond with symptomatology found in life-threatening medical disorders (eg, pulmonary embolus). Remember that panic disorder is a diagnosis of exclusion.
  • Patients with panic disorder are twice as likely as the population to use alternative therapies. Use of dietary supplements (eg, herbs) should be discussed to avoid drug interactions.
 


More on Panic Disorders

Overview: Panic Disorders
Differential Diagnoses & Workup: Panic Disorders
Treatment & Medication: Panic Disorders
Follow-up: Panic Disorders
References
Further Reading
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References

  1. Warshaw MG, Dolan RT, Keller MB. Suicidal behavior in patients with current or past panic disorder: five years of prospective data from the Harvard/Brown Anxiety Research Program. Am J Psychiatry. Nov 2000;157(11):1876-8. [Medline].

  2. Wedekind D, Bandelow B, Broocks A, et al. Salivary, total plasma and plasma free cortisol in panic disorder. J Neural Transm. 2000;107(7):831-7. [Medline].

  3. Neumeister A, Bain E, Nugent AC. Reduced serotonin type 1A receptor binding in panic disorder. J Neurosci. Jan 21 2004;24(3):589-91. [Medline].

  4. Johnson MR, Lydiard RB, Ballenger JC. Panic disorder. Pathophysiology and drug treatment. Drugs. Mar 1995;49(3):328-44. [Medline].

  5. Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuropsychopharmacol Biol Psychiatry. Oct 2000;24(7):1069-89. [Medline].

  6. Vythilingam M, Anderson ER, Goddard A, et al. Temporal lobe volume in panic disorder--a quantitative magnetic resonance imaging study. Psychiatry Res. Aug 28 2000;99(2):75-82. [Medline].

  7. Lee HB, Hening WA, Allen RP, Kalaydjian AE, Earley CJ, Eaton WW, et al. Restless legs syndrome is associated with DSM-IV major depressive disorder and panic disorder in the community. J Neuropsychiatry Clin Neurosci. Winter 2008;20(1):101-5. [Medline].

  8. Kaiya H, Sugaya N, Iwasa R, Tochigi M. Characteristics of fatigue in panic disorder patients. Psychiatry Clin Neurosci. Apr 2008;62(2):234-7. [Medline].

  9. Schmidt NB, Lerew DR, Santiago H, et al. Effects of heart-rate feedback on estimated cardiovascular fitness in patients with panic disorder. Depress Anxiety. 2000;12(2):59-66. [Medline].

  10. Sullivan GM, Kent JM, Kleber M. Effects of hyperventilation on heart rate and QT variability in panic disorder pre- and post-treatment. Psychiatry Res. Jan 30 2004;125(1):29-39. [Medline].

  11. Fleet RP, Martel JP, Lavoie KL, et al. Non-fearful panic disorder: a variant of panic in medical patients?. Psychosomatics. Jul-Aug 2000;41(4):311-20. [Medline].

  12. Katerndahl DA, Talamantes M. A comparison of persons with early-versus late-onset panic attacks. J Clin Psychiatry. Jun 2000;61(6):422-7. [Medline].

  13. Dannon PN, Lowengrub K, Amiaz R. Comorbid cannabis use and panic disorder: short term and long term follow-up study. Hum Psychopharmacol. Mar 2004;19(2):97-101. [Medline].

  14. Schifano F, Di Furia L, Forza G, et al. MDMA ('ecstasy') consumption in the context of polydrug abuse: a report on 150 patients. Drug Alcohol Depend. Sep 1 1998;52(1):85-90. [Medline].

  15. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement on panic disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 1998;59 Suppl 8:47-54. [Medline].

  16. Baldwin DS, Birtwistle J. The side effect burden associated with drug treatment of panic disorder. J Clin Psychiatry. 1998;59 Suppl 8:39-44; discussion 45-6. [Medline].

  17. Bandelow B, Behnke K, Lenoir S. Sertraline versus paroxetine in the treatment of panic disorder: an acute, double-blind noninferiority comparison. J Clin Psychiatry. Mar 2004;65(3):405-13. [Medline].

  18. Bakker A, van Balkom AJ, van Dyck R. Selective serotonin reuptake inhibitors in the treatment of panic disorder and agoraphobia. Int Clin Psychopharmacol. Aug 2000;15 Suppl 2:S25-30. [Medline].

  19. Cloos JM. The treatment of panic disorder. Curr Opin Psychiatry. Jan 2005;18(1):45-50. [Medline].

  20. [Best Evidence] Furukawa TA, Watanabe N, Churchill R. Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review. Br J Psychiatry. Apr 2006;188:305-12. [Medline].

  21. Gomez-Caminero A, Blumentals WA, Russo LJ. Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database. Psychosom Med. Sep-Oct 2005;67(5):688-91. [Medline].

  22. Fleet R, Lesperance F, Arsenault A, et al. Myocardial perfusion study of panic attacks in patients with coronary artery disease. Am J Cardiol. Oct 15 2005;96(8):1064-8. [Medline].

  23. Clum GA, Clum GA, Surls R. A meta-analysis of treatments for panic disorder. J Consult Clin Psychol. Apr 1993;61(2):317-26. [Medline].

  24. Davidson JR. The long-term treatment of panic disorder. J Clin Psychiatry. 1998;59 Suppl 8:17-21; discussion 22-3. [Medline].

  25. den Boer JA. Pharmacotherapy of panic disorder: differential efficacy from a clinical viewpoint. J Clin Psychiatry. 1998;59 Suppl 8:30-6; discussion 37-8. [Medline].

  26. Fleet RP, Dupuis G, Marchand A, et al. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. Oct 1996;101(4):371-80. [Medline].

  27. Fleet RP, Marchand A, Dupuis G, et al. Comparing emergency department and psychiatric setting patients with panic disorder. Psychosomatics. Nov-Dec 1998;39(6):512-8. [Medline].

  28. Hofmann SG, Spiegel DA. Panic control treatment and its applications. J Psychother Pract Res. 1999;8(1):3-11. [Medline].

  29. Katerndahl DA. Panic attacks and panic disorder. J Fam Pract. Sep 1996;43(3):275-82. [Medline].

  30. Kjernisted K, McIntosh D. Venlafaxine extended release (XR) in the treatment of panic disorder. Ther Clin Risk Manag. Mar 2007;3(1):59-69. [Medline].

  31. Loerch B, Graf-Morgenstern M, Hautzinger M, et al. Randomised placebo-controlled trial of moclobemide, cognitive-behavioural therapy and their combination in panic disorder with agoraphobia. Br J Psychiatry. Mar 1999;174:205-12. [Medline].

  32. Margraf J, Barlow DH, Clark DM, et al. Psychological treatment of panic: work in progress on outcome, active ingredients, and follow-up. Behav Res Ther. Jan 1993;31(1):1-8. [Medline].

  33. Michelson D, Pollack M, Lydiard RB, et al. Continuing treatment of panic disorder after acute response: randomised, placebo-controlled trial with fluoxetine. The Fluoxetine Panic Disorder Study Group. Br J Psychiatry. Mar 1999;174:213-8. [Medline].

  34. Michelson LK, Marchione K. Behavioral, cognitive, and pharmacological treatments of panic disorder with agoraphobia: critique and synthesis. J Consult Clin Psychol. Feb 1991;59(1):100-14. [Medline].

  35. Otto MW, Pollack MH, Maki KM. Empirically supported treatments for panic disorder: costs, benefits, and stepped care. J Consult Clin Psychol. Aug 2000;68(4):556-63. [Medline].

  36. Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. Sep 1998;155(9):1189-95. [Medline].

  37. Rickels K, Schweizer E. Panic disorder: long-term pharmacotherapy and discontinuation. J Clin Psychopharmacol. Dec 1998;18(6 Suppl 2):12S-18S. [Medline].

  38. Roy-Byrne P, Stein M, Bystrisky A, et al. Pharmacotherapy of panic disorder: proposed guidelines for the family physician. J Am Board Fam Pract. Jul-Aug 1998;11(4):282-90. [Medline].

  39. Roy-Byrne PP. Integrated treatment of panic disorder. Am J Med. Jan 24 1992;92(1A):S. [Medline].

  40. Roy-Byrne PP, Stein MB, Russo J, et al. Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. J Clin Psychiatry. Jul 1999;60(7):492-9; quiz 500. [Medline].

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Further Reading

Clinical guidelines
Practice guideline for the treatment of patients with panic disorder, second edition. Work Group on Panic Disorder. American Psychiatric Association. 2009

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Keywords

panic disorder, panic attack, panic attacks, anxiety attack, mood disorder, nonfearful panic disorder, NFPD, anxiety disorders, agoraphobia, psychiatric disorder, PD

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Contributor Information and Disclosures

Author

Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Michael C Plewa, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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