eMedicine Specialties > Emergency Medicine > Psychosocial
Panic Disorders: Treatment & Medication
Updated: May 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Supplemental oxygen and cardiac monitoring are recommended for patients experiencing dyspnea or chest pain.
Emergency Department Care
- Patients with chest pain, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or Fowler position; monitor them with pulse oximetry, ECG, and frequent 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 education 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 allow a 30-50% placebo response rate.
- The ED 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, Ativan 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 ED is appropriate in a very limited subset of patients with panic disorder who are very motivated, cooperative, 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.
Consultations
- Consult a cardiologist for patients with abnormal ECG findings, ventricular dysrhythmia, abnormal cardiac examination, or risk factors for ischemic heart disease.
- 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.
Medication
Aside from IV medications required to treat acute anxiety states in the ED, the use of pharmacotherapy for patients with panic disorder (PD) should, in most instances, be deferred to the primary physician or psychiatrist who is monitoring the patient long term. Benzodiazepines are optimal for ED and outpatient abortive therapy because of their immediate antipanic effects. Selective serotonin reuptake inhibitors (SSRIs) are becoming first-line preventive agents in panic disorder because of a better safety profile.15,16 Some patients will require concomitant benzodiazepine with SSRI therapy for the first several weeks of SSRI therapy.
Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are used in refractory cases. Coexisting disorders may influence medication choice (eg, MAOIs, clonazepam, or SSRIs for social phobia; SSRIs or clomipramine [Anafranil] for obsessive-compulsive disorder; TCAs for depression). Beta-blockers, clonidine, and buspirone, although promising in theory, have had poor efficacy in panic disorder. Newer agents such as bupropion (Wellbutrin), nefazodone (Serzone), mirtazapine (Remeron), and the serotonin norepinephrine reuptake inhibitors (SNRIs), venlafaxine (Effexor) and duloxetine (Cymbalta), have not been FDA approved for use in panic disorder. Older agents, such as valproate (Depakote) and hydroxyzine (Vistaril), may also be effective, but they have not been FDA approved for use in panic disorder.
Aripiprazole (Abilify), olanzapine (Zyprexa), or tiagabine (Gabitril) may be effective in augmentation therapy, in combination with an SSRI, in resistant panic disorder cases.
Benzodiazepines
These should not be prescribed to patients who have a history of alcohol and/or drug abuse or emotional dependence. Most common side effects are sedation, somnolence, memory impairment, and poor coordination.
Alprazolam has been studied best and is an effective agent with a rapid (20-min) onset and short (12- to 15-h) half-life. An extended-release formulation is now available for patients on long-term therapy or during the initial titrating phase of an SSRI or TCA. Lorazepam has also been used but is more habituating and results in depression in some patients. Some psychiatrists think that the longer-acting benzodiazepines (eg, diazepam, clonazepam) also have advantages.
Benzodiazepine dependence occurs in as many as 30% of long-term users (>8 wk). Many think that after 6 months they should be slowly tapered (over several weeks to months) to avoid withdrawal and precipitating panic. Withdrawal symptoms include anxiety, insomnia, tremor, impaired concentration, lethargy, dysphoria, headaches, gastrointestinal disturbances, dizziness, photophobia, and hyperacusis. Concomitant therapy with TCAs, SSRIs, antiepileptics, or propranolol may be beneficial, although the withdrawal symptoms do not predict success of eventual discontinuation.
Alprazolam (Xanax, Xanax XR)
For management of anxiety attacks. Binds receptors at several sites within the central nervous system, including limbic system and reticular formation. Effects may be mediated through GABA receptor system.
Adult
Xanax: 0.25-0.5 mg PO tid; average effective dose 0.5-4 mg/d PO
Xanax XR: 0.5-1 mg qam initially, titrate by 1-mg/d increments over 3-4 d to 3-6 mg/d
Pediatric
<18 years: Not established
>18 years: Administer as in adults
Carbamazepine and disulfiram decrease effects; toxicity increases with cimetidine, lithium, contraceptives, ketoconazole or itraconazole (CYP3A4 inhibitors), and CNS depressants (including alcohol)
Documented hypersensitivity; severe respiratory depression; narrow-angle glaucoma; preexisting hypotension
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Withdrawal symptoms, including seizures, may occur upon abrupt discontinuation of drug
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Individualize dosage and increase cautiously to avoid adverse effects.
Adult
2-10 mg PO bid/qid
Pediatric
<6 months: Not recommended
>6 months: 1-2.5 mg PO tid/qid initially, increase gradually prn and as tolerated
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohol, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Clonazepam (Klonopin)
Long-acting benzodiazepine that increases the presynaptic GABA inhibition and reduces the monosynaptic and polysynaptic reflexes. Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters. Has multiple indications, including suppression of myoclonic, akinetic, or petit mal seizure activity and focal or generalized dystonias (eg, tardive dystonia). Reaches peak plasma concentration at 2-4 h after oral or rectal administration.
Adult
0.5-2 mg PO bid/tid
Pediatric
Not established
Phenytoin and barbiturates may reduce effects; coadministration of CNS depressants increase toxicity
Documented hypersensitivity; severe liver disease and acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation of the medication
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. This medication is excellent when patient must be sedated for >24-h period.
Adult
0.5-1 mg IV/IM or 1-2 mg PO bid/tid
Elderly: Begin with half dose
Pediatric
Not established
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAO inhibitors
Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma; reversal agents (eg, flumazenil) contraindicated when lorazepam used for life-threatening conditions (eg, control of intracranial pressure or status epilepticus)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Triazolopyridine agents
The mechanism of antidepressant action of this class of drugs is not fully understood in humans. They are not MAOIs and, unlike amphetamine-type drugs, do not stimulate the CNS.
Trazodone (Desyrel)
Useful in the treatment of PD and agoraphobia with panic attacks. Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Also has negligible affinity for cholinergic and histaminergic receptors.
In animals, selectively inhibits serotonin uptake by brain synaptosomes and potentiates the behavioral changes induced by the serotonin precursor, 5-hydroxytryptophan.
Adult
Initial: 150 mg/d, may increase by 50 mg/d PO q3-4d; not to exceed 400 mg/d in divided doses; average dose is 300 mg/d
Maintenance: Once an adequate response has been achieved, dosage may be gradually reduced with subsequent adjustment depending on response; keep dose at lowest effective level
Pediatric
<6 years: Not established
>6 years: 1.5-2 mg/kg/d in divided doses initially; increase dose gradually q3-4d prn; not to exceed 6 mg/kg/d
May enhance response to alcohol, barbiturates, and other CNS depressants; concurrent use may increase digoxin and phenytoin serum levels; may decrease hypoprothrombinemic effects of warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypotension, including orthostatic hypotension and syncope, has occurred; may produce drowsiness, dizziness, or blurred vision; patients taking this medication should observe caution while driving or performing other tasks requiring alertness, coordination, or dexterity
Selective serotonin reuptake inhibitors
May take from 2-6 weeks to become effective and can result in initial anxiogenic effects, especially with higher doses. Therefore, initial doses should be lower than doses used to treat depression, and they should be titrated up over several weeks. Patients may require concomitant therapy with benzodiazepines for the first several weeks. SSRIs are uniquely effective in PD coexisting with obsessive-compulsive disorder. Sertraline (Zoloft) may be better tolerated than paroxetine (Paxil).17 Fluvoxamine (Luvox), fluoxetine (Prozac), citalopram (Celexa), and escitalopram (Lexapro) are also effective.18 Common adverse effects include gastrointestinal problems, headache, dry mouth, insomnia, nervousness, agitation, and difficulty reaching orgasm.
Paroxetine (Paxil) may increase the suicide risk in children and adolescents with major depressive disorder. If paroxetine is discontinued, as with all SSRIs, tapering should occur over several weeks.
Paroxetine (Paxil)
Alternative DOC. Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake.
Adult
Initial: 10 mg/d PO followed by 10-mg/d PO increments prn; dose changes should occur at intervals of at least 1 wk; usual dose range is 10-60 mg/d; not to exceed 60 mg/d
Maintenance: Make dose adjustments to maintain patient on the lowest effective dosage and reassess periodically to determine the need for continued treatment
Pediatric
<18 years: Not established
>18 years: Administer as in adults
Phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Documented hypersensitivity; concurrent administration with MAOIs or administration within 14 d of discontinuing MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of seizures, mania, renal disease, and cardiac disease
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake. Also has a weak inhibitory effect on norepinephrine and dopamine neuronal reuptake.
Adult
25 mg PO qd; increase to 50 mg PO qd after 1 wk
Pediatric
Not established
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in preexisting seizure disorders and in those that have experienced a recent MI, unstable heart disease, and hepatic or renal impairment
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than tricyclic antidepressants.
Adult
50 mg/dose PO hs initially; increase dose in 50-mg increments q4-7d, as tolerated, until maximum therapeutic benefit achieved; divide total daily dose into 2 doses; if doses are unequal, administer larger dose hs; not to exceed 300 mg/d
Pediatric
<8 years: Not established
>8 years: 25 mg PO initially as single daily dose hs; increase dose in 25-mg increments PO q4-7d as tolerated, until maximum therapeutic benefit achieved; divide total daily doses >50 mg into 2 doses; if not equal, administer larger dose hs; not to exceed 200 mg/d
Risk of a hypertensive crisis increases with coadministration with MAOIs; potentiates effect of triazolam and alprazolam, and thus, when taking them concurrently, dose should be reduced by at least 50%; also reduce the dose of theophylline by one third and monitor plasma levels if taking concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine
Documented hypersensitivity; current use of MAOIs or use in previous 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver dysfunction, cardiovascular disease, history of seizures, or suicidal tendencies
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
Adult
5-10 mg/d PO qam; increase after several wk by 20 mg/d; not to exceed 80 mg/d
Pediatric
<18 years: Not established; initial doses of 20 mg/d in children 6-14 y have been used
>18 years: Administer as in adults
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein bound drugs
Documented hypersensitivity; use of MAOIs or use in the last 2 wk
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating therapy
Tricyclic antidepressants
These agents have the advantages of once daily dosing, low risk of dependence, and no dietary restrictions. However, they are discontinued in 35% of cases because of adverse effects, such as blurred vision, dry mouth, dizziness, weight gain, gastrointestinal disturbance, agitation, insomnia, headache, and decreased libido or ability to orgasm. TCAs must be started in low doses to avoid amphetaminelike stimulation and can require up to 8-12 weeks for treatment response.
Imipramine (Tofranil)
Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neuron.
Use parenteral administration for starting therapy only in patients unable or unwilling to use PO medication.
Adult
10 mg/d PO increasing by 10 mg q2-4d for 2 wk, then by 25 mg q2-3d to 100 mg/d hs; up to 100 mg/d IM divided tid/qid; change to PO route as soon as possible
Pediatric
Not established; recommended dose is 1.5 mg/kg/d PO, with dosage increments of 1 mg/kg q3-4d; not to exceed 5 mg/kg qd or divided bid/qid
Adolescents: 25-50 mg/d PO initially with dosage increased by increments prn; not to exceed 100 mg/d
Increases toxicity of sympathomimetic agents, such as isoproterenol and epinephrine, by potentiating effects and inhibiting antihypertensive effects of clonidine
Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following myocardial infarction; current use of MAOIs or fluoxetine or use in the previous 2 wk
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or receiving thyroid replacement
Desipramine (Norpramin)
May increase synaptic concentration of norepinephrine in CNS by inhibiting reuptake by presynaptic neuronal membrane. May have effects in the desensitization of adenyl cyclase, down-regulation of beta-adrenergic receptors, and down-regulation or serotonin receptors.
Adult
10-250 mg/d PO
Pediatric
Not established
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects increase with phenytoin, carbamazepine, and barbiturates
Documented hypersensitivity; narrow-angle glaucoma; recent postmyocardial infarction; current use of MAOIs or fluoxetine or use in the previous 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Clomipramine (Anafranil)
Affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite desmethylclomipramine.
Adult
25-100 mg/d PO
Pediatric
Not established
Barbiturates, phenytoin, and carbamazepine decrease effects; increases effects of anticholinergics, sympathomimetics, alcohol, and CNS depressants; toxicity of MAOIs increases
Documented hypersensitivity; recent MI; use of MAOIs within 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe cardiopulmonary or renal impairment and in persons unable to metabolize sorbitol
Monoamine oxidase inhibitors
They are effective in patients with social phobia. Advantages of MAOIs are low risk of dependence and less anticholinergic effect than TCAs. Disadvantages are the higher number of adverse effects, including sexual difficulty, hypotension, weight gain, dry mouth, tachycardia, insomnia, drowsiness, headache, weakness, and constipation.
Phenelzine (Nardil)
MAOI most commonly used for PD. Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of PD. Usually reserved for patients who do not tolerate or respond to traditional cyclic or second-generation antidepressants.
Adult
15 mg PO divided tid initially; increase gradually to 60-90 mg/d prn during early phase of treatment; after maximum benefit, reduce dosage slowly over several wk
15 mg/d or qod maintenance; may continue taking medication for as long as required
Pediatric
<16 years: Not recommended
>16 years: Administer as in adults
Increases effects and/or toxicity of barbiturates and CNS depressants; toxicity increases when taken concurrently with fluoxetine, disulfiram, levodopa, sympathomimetics, and tyramine-containing foods
Documented hypersensitivity; pheochromocytoma; hepatic or renal disease; cardiovascular disease; cerebrovascular defect
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperactive or hyperexcitable disorders and glaucoma
Tranylcypromine (Parnate)
Also effective in PD. Binds irreversibly to MAO, thereby reducing monoamine breakdown and enhancing synaptic availability.
Adult
30-60 mg/d PO
Pediatric
Not established
Increases effects and/or toxicity of barbiturates and CNS depressants; toxicity increases when taken concurrently with fluoxetine, disulfiram, levodopa, sympathomimetics, and tyramine-containing foods
Documented hypersensitivity; pheochromocytoma; hepatic or renal disease; cardiovascular disease; cerebrovascular defect
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperactive or hyperexcitable disorders and glaucoma
More on Panic Disorders |
| Overview: Panic Disorders |
| Differential Diagnoses & Workup: Panic Disorders |
 Treatment & Medication: Panic Disorders |
| Follow-up: Panic Disorders |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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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
Keywords
panic disorder, panic attack, panic attacks, anxiety attack, mood disorder, nonfearful panic disorder, NFPD, anxiety disorders, agoraphobia, psychiatric disorder, PD
