Each recommendation is identified as falling into one of three
categories of endorsement, indicated by a bracketed Roman numeral
following the statement. The three categories represent varying
levels of clinical confidence:
[I] Recommended with substantial clinical
confidence
[II] Recommended with moderate clinical
confidence
[III] May be recommended on the basis of
individual circumstances
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B. Psychiatric Management
Panic disorder is a common and often disabling mental disorder.
Treatment is indicated when symptoms of the disorder interfere with
functioning or cause significant distress [I]. Effective
treatment for panic disorder should lead not only to reduction in
frequency and intensity of panic attacks, but also reductions in
anticipatory anxiety and agoraphobic avoidance, optimally with full
remission of symptoms and return to a premorbid level of functioning [I].
Psychiatric management consists of a comprehensive array of activities and
interventions that should be instituted for all patients with panic
disorder, in combination with specific modalities that have demonstrated
efficacy [I].
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1. Establishing a
therapeutic alliance
Psychiatrists should work to establish and maintain a therapeutic
alliance so that the patient's care is a collaborative
endeavor [I]. Careful attention to the patient's
preferences and concerns with regard to treatment is essential to
fostering a strong alliance [I]. In addition,
education about panic disorder and its treatment should be provided
in language that is readily understandable to the patient [I].
Many patients with panic disorder are fearful of certain aspects
of treatment (e.g., medication side effects, confronting agoraphobic
situations). A strong therapeutic alliance is important in supporting
the patient through phases of treatment that may be anxiety provoking [I].
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2. Performing the
psychiatric assessment
Patients should receive a thorough diagnostic evaluation both
to establish the diagnosis of panic disorder and to identify other
psychiatric or general medical conditions [I].
This evaluation generally includes a history of the present illness and
current symptoms; past psychiatric history; general medical history;
history of substance use; personal history (e.g., major life events);
social, occupational, and family history; review of the patient's
medications; previous treatments; review of systems; mental status
examination; physical examination; and appropriate diagnostic tests
(to rule out possible medical causes of panic symptoms) as indicated [I].
Assessment of substance use should include illicit drugs, prescribed and
over-the-counter medications, and other substances (e.g., caffeine)
that may produce physiological effects that can trigger or exacerbate
panic symptoms [I].
Delineating the specific features of panic disorder that characterize
a given patient is an essential element of assessment and treatment
planning [I]. It is crucial to determine if agoraphobia
is present and to establish the extent of situational fear and avoidance [I].
The psychiatrist also should evaluate other psychiatric disorders,
as co-occurring conditions may affect the course, treatment, and
prognosis of panic disorder [I]. It must be determined
that panic attacks do not occur solely as a result of a general
medical condition or substance use and that they are not better
conceptualized as a feature of another diagnosis [I].
The presence of medical disorders, substance use, and other psychiatric
disorders does not preclude a concomitant diagnosis of panic disorder.
If the symptoms of panic disorder are not deemed solely attributable
to these factors, then diagnosing (and treating) both panic disorder
and another condition may be warranted [I].
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3. Tailoring the
treatment plan for the individual patient
Tailoring the treatment plan to match the needs of the particular
patient requires a careful assessment of the frequency and nature
of the patient's symptoms [I]. It may
be helpful, in some circumstances, for patients to monitor their
panic symptoms using techniques such as keeping a daily diary [I]. Such
monitoring can aid in identification of triggers for panic symptoms,
which may become a focus of subsequent intervention.
Continuing evaluation and management of co-occurring psychiatric
and/or medical conditions is also essential to developing
a treatment plan for an individual patient [I].
Co-occurring conditions may influence both selection and implementation
of pharmacological and psychosocial treatments for panic disorder [I].
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4. Evaluating the
safety of the patient
A careful assessment of suicide risk is necessary for all
patients with panic disorder [I]. Panic disorder
has been shown to be associated with an elevated risk of suicidal
ideation and behavior, even in the absence of co-occurring conditions such
as major depression. An assessment of suicidality includes identification
of specific psychiatric symptoms known to be associated with suicide
attempts or suicide; assessment of past suicidal behavior, family
history of suicide and mental illness, current stressors, and potential
protective factors such as positive reasons for living; and specific
inquiry about suicidal thoughts, intent, plans, means, and behaviors [I].
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5. Evaluating types
and severity of functional impairment
Panic disorder can impact numerous spheres of life including work,
school, family, social relationships, and leisure activities. The
psychiatrist should develop an understanding of how panic disorder
affects the patient's functioning in these domains [I] with
the aim of developing a treatment plan intended to minimize impairment [I].
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6. Establishing goals
for treatment
All treatments for panic disorder aim to reduce the frequency and
intensity of panic attacks, anticipatory anxiety, and agoraphobic
avoidance, optimally with full remission of symptoms and return
to a premorbid level of functioning [I]. Treatment
of co-occurring psychiatric disorders when they are present is an
additional goal [I]. The intermediate objectives
that will help achieve these goals will depend on the chosen modality
or modalities [I].
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7. Monitoring the
patient's psychiatric status
The different elements of panic disorder may resolve at different
points during the course of treatment (e.g., panic attacks may remit
before agoraphobic avoidance is eliminated). The psychiatrist should
continue to monitor the status of all symptoms originally presented
by the patient [I]. Psychiatrists may consider
using rating scales to help monitor the patient's status
at each session [I]. Patients also can be asked
to keep a daily diary of panic symptoms to aid in ongoing assessment [I].
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8. Providing education
to the patient and, when appropriate, to the family
Education alone may relieve some of the symptoms of panic disorder
by helping the patient realize that his or her symptoms are neither
life-threatening nor uncommon. Thus, once a diagnosis of panic disorder
is made, the patient should be informed of the diagnosis and educated
about panic disorder and treatment options [I].
Regardless of the treatment modality selected, it is important to
inform the patient that in almost all cases the physical sensations
that characterize panic attacks are not acutely dangerous and will
abate [I]. Educational tools such as books, pamphlets,
and trusted web sites can augment the face-to-face education provided
by the psychiatrist [I].
Providing the family with accurate information about panic
disorder and its treatment is also important for many patients [I].
Education sometimes includes discussion of how changes in the patient's
status affect the family system and of how responses of family members
can help or hinder treatment of the patient's panic disorder [II].
Patient education also includes general promotion of healthy
behaviors such as exercise, good sleep hygiene, and decreased use
of caffeine, tobacco, alcohol, and other potentially deleterious
substances [I].
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9. Coordinating the
patient's care with other clinicians
Many patients with panic disorder will be evaluated by or
receive treatment from other health care professionals in addition
to the psychiatrist. Under such circumstances, the clinicians should
communicate periodically to ensure that care is coordinated and
that treatments are working in synchrony [I].
It is important to ensure that a general medical evaluation has
been done (either by the psychiatrist or by another health care
professional) to rule out medical causes of panic symptoms [I].
Extensive or specialized testing for medical causes of panic symptoms
is usually not indicated but may be conducted based on individual
characteristics of the patient [III].
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10. Enhancing treatment
adherence
Problems with treatment adherence can result from a variety
of factors (e.g., avoidance that is a manifestation of panic disorder, logistical
barriers, cultural or language barriers, problems in the therapeutic
relationship). Whenever possible, the psychiatrist should assess
and acknowledge potential barriers to treatment adherence and should
work collaboratively with the patient to minimize their influence [I].
Many standard pharmacological and psychosocial treatments for
panic disorder can be associated with short-term intensification
of anxiety (e.g., because of medication side effects or exposure
to fear cues during therapy). These temporary increases in anxiety
may contribute to decreased treatment adherence. The psychiatrist
should adopt a stance that encourages patients to articulate their
fears about treatment and should provide patients with a realistic
notion of what they can expect at different points in treatment [I].
In particular, patients should be informed about when a positive
response to treatment can be expected so that they do not prematurely
abandon treatment due to misconceptions about the time frame for
response [I]. Patients should also be encouraged
to contact the psychiatrist (e.g., by telephone if between visits)
if they have concerns or questions, as these can often be readily
addressed and lead to enhanced treatment adherence [I].
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11. Working with
the patient to address early signs of relapse
Although standard treatments effectively reduce the burden of
panic disorder for the majority of patients, even some patients
with a good treatment response may continue to have lingering symptoms
(e.g., occasional panic attacks) or have a recurrence of symptoms
after remission. Patients should be reassured that fluctuations
in symptoms can occur during the course of treatment before an acceptable
level of remission is reached [I]. Patients should
also be informed that symptoms of panic disorder may recur even
after remission and be provided with a plan for how to respond [I].
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C. Formulation and Implementation
of a Treatment Plan
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1. Choosing a treatment
setting
The treatment of panic disorder is generally conducted entirely
on an outpatient basis, as the condition by itself rarely warrants
hospitalization [I]. However, it may be necessary
to hospitalize a patient with panic disorder because of symptoms of
co-occurring disorders (e.g., when acute suicidality associated
with a mood disorder is present or when inpatient detoxification
is required for a substance use disorder) [I].
Under such circumstances, the treatment of panic disorder can be initiated
in the hospital along with treatment of the disorder that prompted
hospitalization [I]. Rarely, hospitalization or partial
hospitalization is required in very severe cases of panic disorder
with agoraphobia when administration of outpatient treatment has
been ineffective or is impractical [I]. Home visits
are another treatment option for patients with severe agoraphobia
who are limited in their ability to travel or leave the house [II].
When accessibility to mental health care is limited (e.g., in remote
or underserved areas), telephone- or Internet-based treatments may
be considered [II].
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2. Choosing an initial
treatment modality
A range of specific psychosocial and pharmacological interventions
have proven benefits in treating panic disorder. The use of a selective
serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake
inhibitor (SNRI), tricyclic antidepressant (TCA), benzodiazepine
(appropriate as monotherapy only in the absence of a co-occurring
mood disorder), or cognitive-behavioral therapy (CBT) as the initial treatment
for panic disorder is strongly supported by demonstrated efficacy
in numerous randomized controlled trials [I]. A
particular form of psychodynamic psychotherapy, panic-focused psychodynamic
psychotherapy (PFPP), was effective in one randomized controlled
trial and could be offered as an initial treatment under certain
circumstances [II].
There is insufficient evidence to recommend any of these pharmacological
or psychosocial interventions as superior to the others, or to routinely
recommend a combination of treatments over monotherapy [II].
Although combination treatment does not appear to be significantly
superior to standard monotherapy as initial treatment for most individuals
with panic disorder, psychiatrists and patients may choose this
option based on individual circumstances (e.g., patient preference) [II].
Considerations that guide the choice of an initial treatment modality
include patient preference, the risks and benefits for the particular
patient, the patient's past treatment history, the presence
of co-occurring general medical and other psychiatric conditions,
cost, and treatment availability [I]. Psychosocial
treatment (with the strongest evidence available for CBT) is recommended
for patients who prefer nonmedication treatment and can invest the
time and effort required to attend weekly sessions and complete
between-session practices [I]. One caveat is that
CBT and other specialized psychosocial treatments are not readily
available in some geographic areas. Pharmacotherapy (usually with
an SSRI or SNRI) is recommended for patients who prefer this modality
or who do not have sufficient time or other resources to engage
in psychosocial treatment [I]. Combined treatment
should be considered for patients who have failed to respond to
standard monotherapies and may also be used under certain clinical circumstances
(e.g., using pharmacotherapy for temporary control of severe symptoms
that are impeding the patient's ability to engage in psychosocial
treatment) [II]. Adding psychosocial treatment
to pharmacotherapy either from the start, or at some later point
in treatment, may enhance long-term outcomes by reducing the likelihood
of relapse when pharmacological treatment is stopped [II].
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3. Evaluating whether
the treatment is working
After treatment is initiated, it is important to monitor change in
key symptoms such as frequency and intensity of panic attacks, level
of anticipatory anxiety, degree of agoraphobic avoidance, and severity
of interference and distress related to panic disorder [I].
Effective treatment should produce a decrease in each of these domains,
although some may change more quickly than others. The severity
of co-occurring conditions also should be assessed at regular intervals,
as treatment of panic disorder can influence co-occurring conditions (e.g.,
major depression; other anxiety disorders) [I].
Rating scales are a useful adjunct to ongoing clinical assessment
for the purpose of evaluating treatment outcome [I].
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4. Determining if
and when to change treatment
Some individuals do not respond, or respond incompletely,
to first-line treatments for panic disorder. Whenever treatment response
is unsatisfactory, the psychiatrist should first consider the possible
contribution of fundamental clinical factors such as an underlying
untreated medical illness that accounts for the symptoms, interference
by co-occurring general medical or psychiatric conditions (including
depression and substance use), inadequate treatment adherence, problems
in the therapeutic alliance, the presence of psychosocial stressors, motivational
factors, and inability to tolerate a particular treatment [I].
These potential impediments to successful treatment should be addressed
as early as possible in treatment [I]. In addition,
if panic-related concerns are leading the patient to minimize the
impact of avoidance or accept functional limitations, the patient
should be encouraged to think through the costs and benefits of
accepting versus treating functional limitations [I]. Clinicians
should be reluctant to accept partial improvement as a satisfactory
outcome and should aim for remission whenever feasible [I].
If response to treatment remains unsatisfactory, and if an adequate
trial has been attempted, it is appropriate for the psychiatrist
and the patient to consider a change [I]. Decisions
about whether and how to make changes will depend on the level of
response to the initial treatment (i.e., none versus partial), the
palatability and feasibility of other treatment options for a given
patient, and the level of symptoms and impairment that remain [I].
Persistent significant symptoms of panic disorder despite a lengthy
course of a particular treatment should trigger a reassessment of
the treatment plan, including possible consultation with another
qualified professional [I].
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5. Approaches to
try when a first-line treatment is unsuccessful
If fundamental clinical issues have been addressed and it
is determined that a change is desirable, the psychiatrist and patient
can either augment the current
treatment by adding another agent (in the case of pharmacotherapy)
or another modality (i.e., add CBT if the patient is already receiving pharmacotherapy,
or add pharmacotherapy if the patient is already receiving CBT) [I],
or they can decide to switch to
a different medication or therapeutic modality [I].
Decisions about how to address treatment resistance are usually
highly individualized and based on clinical judgment, since few
studies have tested the effects of specific switching or augmentation strategies.
However, augmentation is generally a reasonable approach if some
significant benefits were observed with the original treatment [II].
On the other hand, if the original treatment failed to provide any
significant alleviation of the patient's symptoms, a switch
in treatment may be more useful [II].
If one first-line treatment (e.g., CBT, an SSRI, an SNRI) has
failed, adding or switching to another first-line treatment is recommended [I].
Adding a benzodiazepine to an antidepressant is a common augmentation
strategy to target residual symptoms [II]. If
the treatment options with the most robust evidence have been unsuccessful,
other options with some empirical support can be considered (e.g.,
a monoamine oxidase inhibitor [MAOI], PFPP) [II].
After first- and second-line treatments and augmentation strategies
have been exhausted (either due to lack of efficacy or intolerance
of the treatment by the patient), less well-supported treatment
strategies may be considered [III]. These include
monotherapy or augmentation with gabapentin or a second-generation
antipsychotic or with a psychotherapeutic intervention other than CBT
or PFPP [III]. Psychiatrists are encouraged to
seek consultation from experienced colleagues when developing treatment
plans for patients whose symptoms have been resistant to standard
treatments for panic disorder [I].
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6. Specific psychosocial
interventions
Psychosocial treatments for panic disorder should be conducted
by professionals with an appropriate level of training and experience
in the relevant approach [I]. Based on the current
available evidence, CBT is the psychosocial treatment that would
be indicated most often for patients presenting with panic disorder [I].
Cognitive-behavioral therapy is a time-limited treatment (generally
10–15 weekly sessions) with durable effects. It can be
successfully administered individually or in a group format [I].
Self-directed forms of CBT may be useful for patients who do not
have ready access to a trained CBT therapist [II].
Cognitive-behavioral therapy for panic disorder generally includes
psychoeducation, self-monitoring, countering anxious beliefs, exposure
to fear cues, modification of anxiety-maintaining behaviors, and
relapse prevention [I]. Exposure therapy, which
focuses almost exclusively on systematic exposure to fear cues,
is also effective [I].
Panic-focused psychodynamic psychotherapy also has demonstrated
efficacy for panic disorder, although its evidence base is more
limited. Panic-focused psychodynamic psychotherapy may be indicated
as an initial psychosocial treatment in some cases (e.g., patient
preference) [II]. Panic-focused psychodynamic
psychotherapy is a time-limited treatment (twice weekly for 12 weeks)
that is administered on an individual basis. Panic-focused psychodynamic
psychotherapy utilizes the general principles of psychodynamic psychotherapy,
with special focus on the transference as the therapeutic agent
promoting change, and encourages patients to confront the emotional
significance of their panic symptoms with the aim of promoting greater
autonomy, symptom relief, and improved functioning. Although psychodynamic psychotherapies
(other than PFPP) that focus more broadly on emotional and interpersonal
issues have not been formally tested for panic disorder, some case
report data and clinical experience suggest this approach may be
useful for some patients [III].
Other psychosocial treatments have not been formally tested
for panic disorder or have proven ineffective (e.g., eye movement
desensitization and reprocessing [EMDR]) or inferior
to standard treatments such as CBT (e.g., supportive psychotherapy).
Group CBT is effective and can be recommended for treatment
of panic disorder [I]. Other group therapies (including
patient support groups) are not recommended as monotherapies for
panic disorder, although they may be useful adjuncts to other effective
treatments for some patients [III].
Couples or family therapy alone is not recommended as a treatment
for panic disorder, although it may be helpful in addressing co-occurring
relationship dysfunction [III]. It can be beneficial
to include significant others in CBT (e.g., partner-assisted exposure
therapy for agoraphobia), especially if they are educated in the
cognitive-behavioral model of panic disorder and enlisted to help
with between-session practices [II]. When pursuing
other treatments for panic disorder (e.g., pharmacotherapy), education
of significant others about the nature of the disorder and enlisting
significant others to improve treatment adherence may also be helpful [III].
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7. Specific pharmacological
interventions
Selective serotonin reuptake inhibitors, SNRIs, TCAs, and benzodiazepines
have demonstrated efficacy in numerous controlled trials and are
recommended for treatment of panic disorder [I].
Monoamine oxidase inhibitors appear effective for panic disorder
but, because of their safety profile, they are generally reserved
for patients who have failed to respond to several first-line treatments [II].
Other medications with less empirical support (e.g., mirtazapine,
anticonvulsants such as gabapentin) may be considered as monotherapies
or adjunctive treatments for panic disorder when patients have failed to
respond to several standard treatments or based on other individual
circumstances [III].
Because SSRIs, SNRIs, TCAs, and benzodiazepines appear roughly
comparable in their efficacy for panic disorder, selecting a medication
for a particular patient mainly involves considerations of side
effects (including any applicable warnings from the U.S. Food and
Drug Administration [FDA]), cost, pharmacological
properties, potential drug interactions, prior treatment history,
co-occurring general medical and psychiatric conditions, and the
strength of the evidence base for the particular medication in treatment
of panic disorder [I]. The relatively favorable
safety and side effect profile of SSRIs and SNRIs makes them the
best initial choice for many patients with panic disorder [I].
Although TCAs are effective, the side effects and greater toxicity
in overdose associated with them often limit their acceptability
to patients and their clinical utility. Selective serotonin reuptake
inhibitors, SNRIs, and TCAs are all preferable to benzodiazepines
as monotherapies for patients with co-occurring depression or substance
use disorders [I]. Benzodiazepines may be especially
useful adjunctively with antidepressants to treat residual anxiety
symptoms [II]. Benzodiazepines may be preferred (as
monotherapies or in combination with antidepressants) for patients
with very distressing or impairing symptoms in whom rapid symptom
control is critical [II]. The benefit of more
rapid response to benzodiazepines must be balanced against the possibilities
of troublesome side effects (e.g., sedation) and physiological dependence
that may lead to difficulty discontinuing the medication [I].
Patients should be educated about the likely time course of
treatment effects associated with a particular medication [I].
Because patients with panic disorder can be sensitive to medication
side effects, low starting doses of SSRIs, SNRIs, and TCAs (approximately
half of the starting doses given to depressed patients) are recommended [I].
The low dose is maintained for several days then gradually increased
to a full therapeutic dose over subsequent days and as tolerated
by the patient [I]. Underdosing of antidepressants
(i.e., starting low and then not increasing gradually to full therapeutic
dosages as needed) is common in treatment of panic disorder and
is a frequent source of partial response or nonresponse [II].
A regular dosing schedule rather than a p.r.n. ("as needed") schedule
is preferred for patients with panic disorder who are taking benzodiazepines [II],
where the goal is to prevent panic attacks rather than reduce symptoms
once an attack has already occurred.
Once an initial pharmacotherapy has been selected, patients
are typically seen every 1–2 weeks when first starting
a new medication, then every 2–4 weeks until the dose is
stabilized [I]. After the dose is stabilized and
symptoms have decreased, patients will most likely require less
frequent visits [I].
When considering any specific medication, the psychiatrist
must balance the risks associated with the medication against the
clinical need for pharmacotherapy [I]. The FDA has
warned of the possibility that antidepressants may increase the
risk of suicidal ideation and behavior in patients age 25 years
and younger; this is an important factor to consider before using
an SSRI, an SNRI, or a TCA for panic disorder. Other important safety
considerations for SSRIs include possible increased likelihood of
upper gastrointestinal bleeding (particularly when taken in combination
with nonsteroidal anti-inflammatory drugs [NSAIDs] or
with aspirin) and increased risk of falls and osteoporotic fractures
in patients age 50 years and older. With venlafaxine extended release
(ER), a small proportion of patients may develop sustained hypertension.
It is recommended that psychiatrists assess blood pressure during
treatment, particularly when venlafaxine ER is titrated to higher
doses [I].
Tricyclic antidepressants should not be prescribed for patients
with panic disorder who also have acute narrow-angle glaucoma or
clinically significant prostatic hypertrophy. Tricyclic antidepressants
may increase the likelihood of falls, particularly among elderly
patients. A baseline electrocardiogram should be considered before
initiating a TCA, because patients with preexisting cardiac conduction abnormalities
may experience significant or fatal arrhythmia with TCA treatment.
Overdoses with TCAs can lead to significant cardiac toxicity and
fatality, and therefore TCAs should be used judiciously in suicidal
patients.
Benzodiazepines may produce sedation, fatigue, ataxia, slurred
speech, memory impairment, and weakness. Geriatric patients taking
benzodiazepines may be at higher risk for falls and fractures. Because
of an increased risk of motor vehicle accidents with benzodiazepine
use, patients should be warned about driving or operating heavy
machinery while taking benzodiazepines [I]. Patients
should also be advised about the additive effects of benzodiazepines
and alcohol [I]. Caution and careful monitoring
is indicated when prescribing benzodiazepines to elderly patients,
those with preexisting cognitive impairment, or those with a history
of substance use disorder [I].
For women with panic disorder who are pregnant, nursing, or
planning to become pregnant, psychosocial interventions should be
considered in lieu of pharmacotherapy [II]. Pharmacotherapy
may also be indicated [III] but requires weighing
and discussion of the potential benefits and risks with the patient,
her obstetrician, and, whenever possible, her partner [I].
Such discussions should also consider the potential risks to the
patient and the child of untreated psychiatric illness, including
panic disorder and any co-occurring psychiatric conditions [I].
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D. Maintaining or Discontinuing
Treatment After Response
Pharmacotherapy should generally be continued for 1 year or more
after acute response to promote further symptom reduction and decrease
risk of recurrence [I]. Incorporating maintenance
treatment (e.g., monthly "booster" sessions focused on
relapse prevention) into psychosocial treatments for panic disorder
also may help maintain positive response [II],
although more systematic investigation of this issue is needed.
Before advising a taper of effective pharmacotherapy, the psychiatrist
should consider several factors, including the duration of the patient's
symptom stability, the presence of current or impending psychosocial
stressors in the patient's life, and the extent to which
the patient is motivated to discontinue the medication [II].
Discussion of medication taper should also include the possible
outcomes of taper, which could include discontinuation symptoms
and recurrence of panic symptoms [I]. If medication
is tapered, it should be done in a collaborative manner with continual
assessment of the effects of the taper and the patient's
responses to any changes that emerge [I].
If a decision is made to discontinue successful treatment with
an SSRI, an SNRI, or a TCA, the medication should be gradually tapered
(e.g., one dosage step down every month or two), thereby providing
the opportunity to watch for recurrence and, if desired, to reinitiate
treatment at a previously effective dose [II].
However, under more urgent conditions (e.g., the patient is pregnant
and the decision is made to discontinue medications immediately),
these medications can be discontinued much more quickly [I].
The approach to benzodiazepine discontinuation also involves
a slow and gradual tapering of dose [I]. Withdrawal symptoms
and symptomatic rebound are commonly seen with benzodiazepine discontinuation,
can occur throughout the taper, and may be especially severe toward
the end of the taper. This argues for tapering benzodiazepines very
slowly for patients with panic disorder, probably over 2–4
months and at rates no higher than 10% of the dose per
week [I]. Cognitive-behavioral therapy may be
added to facilitate withdrawal from benzodiazepines [I].
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II. Formulation and
Implementation of a Treatment Plan
The formulation of a treatment
plan considers the full range of predispositions, precipitants,
and symptoms exhibited by patients with panic disorder. Effective
treatment involves not only resolution of panic attacks but also
satisfactory reductions in anticipatory anxiety and agoraphobic
avoidance, optimally with full remission of symptoms and return
to a premorbid level of functioning.
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A. Psychiatric Management
Psychiatric management consists of a comprehensive array of
activities and interventions that should be instituted by psychiatrists
for all patients with panic disorder, in combination with specific
treatment modalities.
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1. Establishing a
therapeutic alliance
As in all of medical practice, the physician first works to
establish and then to maintain a therapeutic alliance so that the patient's
care is a collaborative endeavor. By the very nature of the illness,
many patients with panic disorder are anxious about treatment. Therefore,
education and support are important components of the psychiatric
management of panic disorder. As is true for most individuals who
are first initiating treatment for psychiatric or general medical
disorders, patients with panic disorder may require additional support
and access to their health care professionals in the early phase
of treatment, before symptoms resolve. Patients should be informed
about courses of action they can pursue if they need help urgently,
such as having the psychiatrist paged, going to the emergency department,
or calling 911. This information should be provided in the context
of education that panic symptoms themselves are rarely dangerous
and that occurrence of panic symptoms does not usually require immediate medical
attention.
Panic disorder can be a chronic condition for which adherence
to a treatment plan is important. Hence, a strong treatment alliance
is crucial. It is often the case that the treatment of panic disorder
involves asking the patient to do things that may be frightening
and uncomfortable, such as confronting agoraphobic situations. Here
again, a strong treatment alliance is necessary to support the patient
in doing these things.
Therapeutic communications explaining panic disorder should
be made in language that is culturally sensitive and worded in a
way that the patient can understand. Careful attention to the patient's
fears and wishes with regard to his or her treatment is essential
in establishing and maintaining the therapeutic alliance. Management
of the therapeutic alliance may involve an awareness of the patient's
beliefs about medication and psychotherapy, cultural differences,
transference, countertransference, and other factors that may influence
the psychiatrist-patient relationship.
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2. Performing the
psychiatric assessment
Patients with panic symptoms should receive a thorough diagnostic
evaluation both to determine whether a diagnosis of panic disorder
is warranted and to identify the presence of other psychiatric or
general medical conditions. This evaluation will generally include
a history of the present illness and current symptoms; past psychiatric
history; general medical history and history of substance use; personal
history (e.g., major life events); social, occupational (including
military), and family history; review of the patient's
medications; review of previous treatments; review of systems; mental
status examination; physical examination; and diagnostic tests (to
rule out possible general medical causes of panic symptoms) as indicated.
Family history of anxiety disorders and childhood traumatic events
are reported more often by patients with panic disorder than by
many comparison groups (3–5),
and longitudinal data suggest that childhood physical and sexual
abuse are risk factors for panic disorder (6). Patients
with panic disorder also report more stressful events in the month
preceding panic onset, compared with control participants (7).
Therefore, the psychiatric assessment should include careful inquiry
about the patient's developmental history, life events,
family history, and the events that preceded onset of the panic
symptoms. Additional details about the general principles and components
of a complete psychiatric evaluation have been outlined in APA's Practice
Guideline for the Psychiatric Evaluation of Adults, Second Edition (8).
Delineating the features of panic disorder that are present in
a given patient is also important in establishing a diagnosis of
panic disorder and developing a plan of treatment. The essential
features of panic disorder are recurrent panic attacks and persistent
concern about these attacks (or change in behavior as a result of
the attacks). Panic attacks are discrete periods of intense fear
or discomfort that have abrupt onset and usually reach a peak within
10 minutes. These attacks are characterized by distressing physical
and psychological symptoms and often by a sense of imminent danger
and an urge to escape. Persistent concern about panic attacks can manifest
in several ways: worry about having additional attacks, worry about
the implications or consequences of the attacks, or changes in behavior
that are intended to prevent attacks or cope with an attack should
one occur. Fear and avoidance of situations and places such as driving,
restaurants, shopping malls, and elevators commonly occur in individuals
with panic disorder; this avoidance is referred to as agoraphobia.
Patients with concurrent agoraphobia fear and/or avoid
situations in which escaping or obtaining help may be difficult
or embarrassing if they have panic symptoms. In any evaluation of
panic disorder, it is crucial to determine if agoraphobia is present
and to establish the extent of situational fear and avoidance. Tables
1, 2, 3, and 4 provide the DSM-IV-TR criteria for the diagnoses of
panic attack, agoraphobia, panic disorder without agoraphobia, and
panic disorder with agoraphobia. More detailed discussion of the diagnostic
features of panic disorder can be found in DSM-IV-TR and in Section
IV.A of this guideline.
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In addition to a full assessment of the features of panic
disorder and agoraphobia, a comprehensive psychiatric assessment
is essential to identify other anxiety disorders, mood disorders,
substance use disorders, personality disorders, and other disorders
that often co-occur with panic disorder (9–33). Co-occurring
psychiatric disorders require particular attention as some of them
affect the course, treatment response, and prognosis of panic disorder
(34).
Establishing the context in which panic attacks occur is important
for accurate diagnosis. Panic attacks frequently occur in other
disorders, and in only a subset of individuals is panic disorder
an appropriate diagnosis. First, it must be determined that panic
attacks do not occur solely as a result of a general medical condition.
Some examples of medical conditions that can be associated with
panic symptoms include hyperthyroidism, hypothyroidism, hypercalcemia,
hypoglycemia, pheochromocytoma, vestibular dysfunction (e.g., Ménière's
disease), seizure disorders, and cardiac conditions such as arrhythmias
and supraventricular tachycardia (35). With most of
these conditions, definitive causal relationships between the general
medical condition and panic disorder have not been established.
Although there appears to be an increased co-occurrence of mitral
valve prolapse and panic disorder (36–39),
mitral valve prolapse is typically an incidental finding in a patient
with panic disorder and does not usually change the treatment plan
(i.e., the panic disorder remains the primary target of treatment).
Section III.B provides further discussion of the impact of co-occurring
medical conditions on treatment planning for panic disorder.
Panic attacks are often associated with intoxication with (e.g.,
cannabis, stimulant) or withdrawal from (e.g., sedative-hypnotic,
alcohol, benzodiazepine) drugs of abuse. Prescription or over-the-counter
medications, including decongestants (pseudoephedrine, phenylpropanolamine),
stimulants, dopaminergic agents, and agents to treat asthma (beta-adrenergic
agonist inhalers, theophylline, steroids) may also induce or worsen
panic attacks. Finally, caffeine and related compounds in beverages
(e.g., coffee, colas, tea, "energy drinks") and
other ingested products (e.g., "energy bars")
can induce panic attacks in anyone at excessive doses (typically
more than 800–1,000 mg/day), but can do so even
at lower doses in individuals susceptible to panic disorder. Reduction
or elimination of intake of such medications and substances may
lead to a marked decrease or cessation of panic episodes.
Psychiatrists also should consider other psychiatric disorders
for which panic attacks can be an associated feature. A diagnosis
of panic disorder requires the presence of at least some unexpected
attacks during the course of illness that are not triggered by a
specific stimulus. Psychiatrists should consider other disorders
when panic attacks appear to be exclusively associated with the
following:
Exposure to a specific feared
situation or stimulus (specific phobia)
Exposure to situations in which the patient fears negative evaluation
(social phobia)
Exposure to the focus of an obsession or a situation
in which the patient was prevented from performing a compulsive
behavior (obsessive-compulsive disorder)
Exposure to a reminder of a traumatic experience or
to a situation in which the patient feels that safety is threatened
(posttraumatic stress disorder)
Intense bouts of worrying (generalized anxiety disorder)
Exposure to separation from home or an attachment figure
in children or adolescents (separation anxiety disorder)
Hallucinations or delusional thinking (psychotic disorders)
Use or withdrawal from use of a substance (substance
use disorders; especially, intoxication with central nervous system
stimulants or cannabis and withdrawal from central nervous system
depressants)
In addition to establishing that panic attacks are not exclusively
associated with the circumstances listed above, it must be determined
that the patient has experienced 1 month or more of worry about
having more attacks, worry about the implications of the attacks,
or panic-related behavioral changes. If a patient reports panic
attacks without associated worry or behavioral change, the psychiatrist
should consider whether panic attacks are an associated feature
of another disorder or represent a subthreshold panic disorder (i.e.,
the patient demonstrates many features of panic disorder but does
not meet full criteria). Although subthreshold panic disorder is
associated with a lesser degree of symptoms, comorbidity, and functional
impairment than full panic disorder (40), subthreshold
panic disorder is often distressing for the patient, can interfere
with functioning, and may progress to full panic disorder in some
individuals (41). Standard treatments for panic disorder
are generally indicated for patients presenting with subthreshold
symptoms, although education or a briefer course of treatment may
be sufficient as a first treatment step if symptoms are mild.
Panic attacks that occur in the absence of worry about the attacks
or behavior change in response to the attacks also may be conceptualized
as associated features of other disorders. For instance, it is fairly
common for patients with mood disorders to report occasional unexpected
panic attacks; however, if persistent concerns about the attacks
and behavioral changes in response to the attacks are both absent,
then the panic attacks should be conceptualized as an associated feature
of the mood disorder. In other cases, patients may present with
panic attacks that are part of a reaction to a specific stressful
situation; in this circumstance, a diagnosis of adjustment disorder
may be indicated. Finally, patients may report panic symptoms that,
upon further examination, appear to be normal reactions to truly
threatening situations (e.g., deployment to a war zone, diagnosis
of a serious illness).
Some patients endorse worry about panic-like symptoms and/or
avoidance of situations because of fears of developing panic-like
symptoms; however, the episodes of fearfulness they describe do
not meet DSM-IV-TR criteria for a panic attack. In these cases,
a diagnosis of agoraphobia without history of panic disorder should
be considered. Patients with this diagnosis often fear and avoid
situations that are commonly avoided by patients with panic disorder
(e.g., crowded places, driving long distances). In contrast to patients
with panic disorder, such patients report only limited symptom attacks
(i.e., subthreshold panic attacks) or perhaps one discrete symptom
(e.g., stomach distress). Standard treatments for panic disorder
(especially cognitive-behavioral approaches) are indicated for most
patients with agoraphobia without history of panic disorder, although
they should be tailored to address the patient's particular
concerns and symptoms.
Some atypical presentations of panic disorder may be misinterpreted
as other disorders. For instance, some patients experience choking
sensations as a prominent symptom of panic and avoid eating many
foods due to fears of choking. Their restricted eating may cause
them to initially appear to have a primary eating disorder. However,
upon further questioning these patients reveal that they avoid eating
certain foods because they fear choking and that the symptoms they
experience while eating are consistent with the definition of a
panic attack. If the patient also reports some unexpected panic
attacks, the diagnosis of panic disorder may be appropriate. If unexpected
attacks are absent, then a specific phobia of choking may be a more
accurate diagnosis. Regardless, determining the concern (fear of
gaining weight versus fear of panicking and choking) that motivates
the problematic behavior (restricted eating) is essential to differential
diagnosis.
Finally, it is important to note that the presence of general medical
conditions, substance use, and other psychiatric disorders does
not preclude a concomitant diagnosis of panic disorder. If the symptoms
of panic disorder are not deemed to be solely attributable to these
factors, then diagnosing both panic disorder and another condition
(medical, psychiatric, or substance related) may be warranted.
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3. Tailoring the
treatment plan for the individual patient
Although patients with panic disorder share common features of
the illness, there may be important individual differences. The
frequency of panic attacks varies widely among patients, and the
symptoms associated with panic attacks can be highly individualized.
For example, some patients report attacks that primarily involve
somatic symptoms (e.g., palpitations, chest pain), whereas others
are more focused on psychological symptoms (e.g., depersonalization,
fear of "going crazy"). The amount of anticipatory
anxiety and the degree of agoraphobic avoidance also vary from patient
to patient. Many patients with panic disorder exhibit only mild
levels of avoidance; at the opposite extreme are patients who will
not leave the house without a trusted companion. Patients also present
with significant variation in their profiles of panic-related apprehension,
which seem to fall into one or more of several major foci of concern (i.e.,
physical, social, or mental catastrophe) (42). Sensitivity
to these individual differences in the elements of panic disorder
is essential for two reasons. First, it is important for the patient
to feel that the psychiatrist understands his or her individual
experience of panic symptoms. Second, treatment selection, delivery,
and response may be influenced by the particular constellation of
symptoms of a given patient.
Tailoring the treatment to match the needs of the particular
patient requires a careful assessment of the frequency and nature
of the patient's symptoms. It may be helpful for patients
to monitor their panic symptoms using techniques such as keeping
a daily diary, in order to gather information regarding the relationship
of panic symptoms to internal stimuli (e.g., emotions) and external
stimuli (e.g., substances, particular situations or settings). Such
monitoring can reveal triggers of panic symptoms that may be the
focus of subsequent intervention.
In addition, it is extremely
important when formulating the treatment plan to address the presence
of any of the many psychiatric and medical conditions that frequently
co-occur with panic disorder. Continuing evaluation and management
of co-occurring conditions are a crucial part of the treatment plan.
In some individuals, treatment of co-occurring conditions may be required
before interventions for panic disorder can become successful. For
example, patients with serious substance use disorders may need
detoxification before it is possible to institute treatment for
panic disorder. However, total abstinence should not usually be
a condition of initiating panic disorder treatment, especially if
the substance use appears to be triggered by panic disorder symptoms.
Symptoms of co-occurring personality disorders (e.g., borderline
personality disorder) may also be so prominent that they interfere
with symptom-based treatment of panic disorder. In these circumstances,
the personality disorder may require appropriate intervention before
or concomitant with the panic treatment (see APA's Practice
Guideline for the Treatment of Patients With Borderline Personality
Disorder [43]).
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4. Evaluating the
safety of the patient
A careful assessment of suicide risk is an essential element
of the evaluation of all patients with panic disorder. Panic disorder
has been shown to be associated with an elevated risk of suicidal
ideation and behavior, even after controlling for the effects of
co-occurring conditions (44). The assessment should
include 1) identification of specific psychiatric symptoms known
to be associated with suicide attempts or suicide, which include
aggression, violence toward others, impulsiveness, hopelessness,
agitation, psychosis, mood disorders, and substance use disorders;
2) assessment of past suicidal behavior, including the intent and
lethality of self-injurious acts; 3) family history of suicide and
mental illness; 4) current stressors such as recent losses, poor
social support, family dysfunction, physical illnesses, chronic
pain, or financial, legal, occupational, or relationship problems;
5) potential protective factors such as positive reasons for living
(e.g., children, other family members, pets, positive therapeutic
relationships, sense of responsibility to others), spirituality/religious beliefs,
or good reality testing, frustration tolerance, or coping skills;
and 6) specific inquiry about suicidal thoughts, intent, plans,
means, and behaviors. For more information about assessing and managing
suicidality, readers may consult APA's Practice
Guideline for the Assessment and Treatment of Patients With Suicidal
Behaviors (45). Issues relating to
the potential for emergence of suicidality with antidepressant treatment
are reviewed in Section II.H.
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5. Evaluating types
and severity of functional impairment
The degree of functional impairment varies considerably among
patients with panic disorder. While panic attack frequency and severity
contribute to functional impairment, so do the extent of anticipatory
anxiety and agoraphobic avoidance. In particular, agoraphobic avoidance
can lead to considerable dysfunction in both work and social domains. Levels
of agoraphobic avoidance and apprehension have been shown to be
stronger predictors of functional impairment and quality of life
than frequency of panic attacks (46). Even after panic
attacks have subsided, the patient may continue to have significant
functional limitations that should be addressed in treatment.
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6. Establishing goals
for treatment
The ultimate goals of first-line
treatments for panic disorder are reducing the frequency and intensity
of panic attacks, anticipatory anxiety, and agoraphobic avoidance, optimally with
full remission of symptoms and attainment of a premorbid level of
functioning. Treatment of co-occurring psychiatric disorders when
they are present is an additional goal. The intermediate objectives
that will help achieve these goals will depend on the chosen modality
or modalities (see Section II.C). For example, in the case of pharmacotherapy
the initial objectives include educating the patient about panic
disorder and medication treatment (including medication side effects), selecting
an appropriate starting dose of medication, titrating up to a therapeutic
dose, promoting adherence to the medication regimen, and recommending
and reinforcing positive behavioral changes. When any psychosocial
treatment is pursued, a coherent explanation of how that treatment
is thought to influence panic disorder should be provided to the patient.
The conceptual model of panic pertinent to the type of therapy or
therapies being deployed, principles of treatment, and expected
outcomes should be made explicit to the patient.
Treatment of panic disorder should also include substantial
effort to alleviate or minimize functional impairment that may be
associated with panic attacks, associated anxiety, and agoraphobic
avoidance. In addressing such functional impairment, it is critical
to determine how patients define satisfactory outcomes and desirable
levels of functioning for themselves, but also to assist patients
who may not believe certain goals are attainable to become aware
of the possibility of functional gains.
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7. Monitoring the
patient's psychiatric status
The different elements of panic disorder often resolve at
different points during the course of treatment. Usually, panic attacks
are controlled first, but subthreshold panic attacks, anticipatory
anxiety, and agoraphobic avoidance often continue and require further
treatment (47). The psychiatrist should continue to
monitor the status of all of the symptoms with which the patient
originally presented and should monitor the effectiveness of the
treatment plan on an ongoing basis. Many illnesses, including depression
and substance use disorders, co-occur with panic disorder at higher
rates than are seen in the general population (33).
Therefore, the psychiatrist should monitor the patient's
mood (and symptoms of any other co-occurring disorder) on an ongoing
basis.
Psychiatrists may consider
using rating scales to help monitor the patient's status
at each session. Other resources provide detailed information about
rating scales that may help with ongoing measurement of the severity
of panic disorder symptoms and symptoms of co-occurring conditions (48, 49).
Rating scales such as the Panic Disorder Severity Scale (PDSS) (50)
may complement the psychiatrist's interview by offering
a quantitative measure of severity that can be tracked over time.
The PDSS can be administered and rated by the psychiatrist (50, 51),
or a self-report version can be used (52). Rating scales
that measure symptoms of anxiety more broadly also may aid in monitoring
the patient's status. The Overall Anxiety Severity and
Impairment Scale (OASIS) (53) is an example of a rating
scale that measures symptoms of anxiety more broadly (i.e., includes
both panic and other anxiety disorder symptoms), which may also
be a useful way to measure outcome for some patients. Many other
rating scales for anxiety, panic symptoms, and agoraphobia are available.
Psychiatrists may refer to clinical handbooks to find other appropriate
measures of panic symptoms as well as measures of common co-occurring
illnesses (e.g., depression). These handbooks offer descriptions
of various rating scales along with information about reliability
and validity, administration and scoring, and instructions about
how to obtain each scale (48, 49).
Psychiatrists also can evaluate the frequency and severity of
a patient's panic symptoms by asking the patient to keep
a daily diary that includes information such as the time, location,
nature, and intensity of panic symptoms. Before instructing patients
to monitor panic symptoms, the psychiatrist should discuss the potential
costs (e.g., temporary increase in anxiety because of increased
focus on symptoms) and benefits (e.g., more accurate assessment
of symptoms than by using retrospective report) of this assessment
strategy (54).
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8. Providing education
to the patient and, when appropriate, to the family
Once the diagnosis of panic disorder is made, the patient
should be informed of the diagnosis and educated about panic disorder, its
clinical course, and its complications. The psychiatrist should
convey hope and reasonable expectations for how treatment will influence
the course of the disorder. Regardless of the treatment modality
selected, it is important to inform the patient that in almost all
cases the physical sensations that characterize panic attacks are
not acutely dangerous and will abate. In a few rare circumstances
(e.g., possible elevated risk of hypoperfusion or placental abruption
in pregnant women with panic attacks), panic attacks may in fact
be associated with harmful effects; this information should be disseminated
as needed for individual patients who present with co-occurring
conditions that put them at risk for possible complications of panic
attacks.
Many patients with panic disorder believe they are suffering
from a disorder of an organ system other than the central nervous
system. They may fervently believe, for example, that they have
heart or lung disease. Partners and involved family members of patients
with panic disorder may share these beliefs, may be frustrated by
the patient's disability, or may insist that absolutely
nothing is wrong with the patient. Educating both the family and
the patient and emphasizing that panic disorder is a real illness
requiring support and treatment can be crucial. Regardless of the
method of treatment selected, successful therapies of panic disorder
usually begin by explaining to the patient that the attacks themselves
are not life-threatening. By helping the patient realize that these
symptoms are neither life-threatening nor uncommon, education alone
may relieve some of the symptoms of panic disorder. This information
also may enhance motivation for treatment. The family may be helped
to understand that panic attacks are terrifying to the patient,
that avoidant behavior can perpetuate panic symptoms, and that the
disorder, unless treated, can interfere significantly with the patient's
life. In addition to receiving education provided by the treating
psychiatrist, patients and their families may benefit from access
to organizations and to materials that promote understanding of
anxiety disorders and other mental health problems (see Appendix).
As with other therapeutic communication, cultural and language differences may
need to be considered and accommodated in imparting information
about panic disorder to patients and their families.
There are rare situations in which agoraphobic avoidance becomes
such a routine part of the patient's life that the family
is actually reluctant to see it remit. A patient who is homebound
because of panic disorder, for example, may have assumed all of
the household chores for the family. Remission of this kind of agoraphobic
avoidance might lead the patient to engage in more activities outside
of the home and create a potential for conflict in the family system.
Without recognizing this, family members might tacitly undermine
a potentially successful treatment to avoid disrupting their ingrained
patterns. It is also possible (although not necessarily common)
that successful resolution of agoraphobia may place strain on significant
relationships as others adjust to the changes in the patient's
ability to pursue independent activities (55). Therefore,
education sometimes includes discussion of how changes in the patient's
status might affect the family system and how responses of family
members can help or hinder treatment of the patient's panic
disorder.
Patient education also includes general promotion of healthy
behaviors such as exercise, good sleep hygiene, and decreased use
of caffeine, tobacco, alcohol, and other potentially deleterious
substances. Preliminary evidence suggests that aerobic exercise
may benefit individuals with panic symptoms (56–59).
Given the myriad health benefits of exercise, even if benefits for
panic disorder are largely unproven, psychiatrists should consider
recommending aerobic exercise (e.g., walking for 60 minutes or running
for 20–30 minutes at least 4 days per week) to patients
who are physically able. However, in doing so the psychiatrist should
consider that fears of physical exertion are common in patients
with panic disorder and that exercise may actually trigger panic
attacks in some patients (although most patients can tolerate exercise without
difficulty) (60). In these individuals, the psychiatrist may
wish to incorporate exercise into the treatment regimen more gradually,
as the patient experiences symptom relief and develops coping skills
for panic symptoms. For patients receiving CBT, aerobic exercise
can be incorporated into the interoceptive exposure component of
treatment.
When co-occurring tobacco use is present, smoking cessation
interventions may be useful adjuncts to standard treatments for
panic disorder. Epidemiologic data suggest that daily smoking increases
risk for panic attacks and panic disorder. Thus, smoking may be
a causal or exacerbating factor in some individuals with panic disorder.
The effects of other substance use disorders on panic disorder symptoms
and treatment are reviewed in Section III.A.2.
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9. Coordinating the
patient's care with other clinicians
Many patients with panic disorder will be evaluated by or
will receive treatment from other health care professionals in addition
to the psychiatrist. Under such circumstances, the clinicians should
communicate periodically to ensure that care is coordinated and
that any treatments are working in synchrony. Psychiatric management
may also involve educating nonpsychiatric health care professionals
about panic disorder, including the ability of panic attacks to
masquerade as other general medical conditions and strategies for
assisting patients who are convinced that panic attacks represent
serious abnormalities of other organ systems.
It is important to ensure that a general medical evaluation has
been done (either by the psychiatrist or by another physician) to
rule out medical causes of panic symptoms. By the time a psychiatrist
is consulted, many patients with panic disorder may already have
undergone medical testing, which the psychiatrist should review.
Generally, physicians should test thyroid-stimulating hormone levels
to rule out thyroid disease and obtain a substance use history (including
caffeine, nicotine, alcohol, and other potentially deleterious substances)
to rule out overuse, abuse, or dependence that could be causing
or exacerbating symptoms of panic disorder. If cardiac symptoms
are prominent, an electrocardiogram may be warranted, and if seizures
are suspected the physician should refer the patient to a neurologist
for evaluation. Extensive or specialized testing for medical causes
is usually not indicated during the initial assessment but may be conducted
based on the patient's specific presentation (e.g., frequent
palpitations may be cause to conduct a Holter monitoring examination
or other specific cardiac tests). In fact, attempting to diagnose
and treat a variety of nonspecific somatic symptoms may delay initiation
of treatment for the panic disorder itself. However, with some patients
it may be therapeutic and enhance the therapeutic alliance to undertake assessment
that will disconfirm other causative sources for the panic attacks.
Therefore, the extent of assessment for medical causes of panic
attacks will vary according to the individual patient.
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10. Enhancing treatment
adherence
The treatment of panic disorder involves confronting many things
that the patient fears. Patients are often afraid of medically adverse
events; hence, they fear taking medications and can be very sensitive
to somatic sensations induced by them (e.g., initial tremulousness
or nervousness caused by antidepressants). As described in Section
II.G.1, patients receiving CBT may be required to confront both
interoceptive fear cues (i.e., feared bodily sensations) and external
fear cues (i.e., agoraphobic situations) and to keep careful records
of anxiety symptoms. These activities may temporarily increase the
patient's anxiety level.
The short-term intensification of anxiety in association with
standard treatments for panic disorder may decrease adherence. For
example, some patients may miss or arrive late for treatment sessions,
may abruptly stop medication, or may not complete required assignments
during CBT. Recognition of these possibilities guides the psychiatrist
to adopt a stance that encourages the patient to articulate his
or her fears. It is also helpful to inform the patient that response
is not likely to be immediate and that there may even be an initial
increase in anxiety as treatment begins. Patients should be educated
that relapses may occur during the course of recovery but that these
events do not typically indicate that treatment will be ineffective
over time. The psychiatrist should indicate how the patient could
obtain help in the event of a severe relapse.
Problems with treatment adherence can result from a variety
of factors. An empathic and nonjudgmental stance can facilitate
discussion of adherence issues such as missed sessions, lapses in
medication use, or failure to complete CBT homework assignments.
In addition, incomplete adherence may simply be a manifestation
of the disorder. For example, the patient might be afraid of somatic
sensations that accompany medication use or be afraid to complete
an exposure to a feared situation. Agoraphobic avoidance might also
cause patients to miss sessions because of fears of leaving the house
or traveling. Psychiatrists should acknowledge the possibility that
anxiety might sometimes interfere with adherence to treatment and
should help patients plan ahead to minimize this possibility. For
example, for a patient who fears driving, initially arrangements
could be made for a family member to drive the patient to sessions.
Family members or other trusted individuals also may play other
helpful roles in improving treatment adherence, such as reminding
the patient to take medication at scheduled times or giving the
patient positive reinforcement for confronting situations previously
avoided.
Adherence may be limited not only by the disorder but also
by practical issues such as scheduling conflicts, lack of transportation
or child care, or insufficient financial resources. With regard
to scheduling, transportation, and child care issues, it is useful
to identify these potential obstacles at an early juncture and help
the patient generate possible solutions. Pharmaceutical companies
may provide free medications for patients with severe financial
limitations, with the exact criteria differing from company to company.
Information on patient assistance programs is available from the
web site of the Partnership for Prescription Assistance (http://www.helpingpatients.org)
and from Rx Assist (http://www.rxassist.org).
Finally, incomplete adherence may reflect issues in the psychiatrist-patient
relationship. If adherence is not improved by measures such as discussing
fears, providing reassurance and nonpunitive acceptance, providing
education, and mobilizing family support, it may indicate more complex
resistance that is not within the patient's awareness and
that may need to become the main focus of treatment.
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11. Working with
the patient to address early signs of relapse
Studies have shown that panic disorder is often a chronic
illness, especially for patients with agoraphobia (61, 62). Symptom
exacerbation can occur even while the patient is undergoing treatment
and may indicate the need for reevaluation of the treatment plan.
Because such exacerbations can be disconcerting, the patient and,
when appropriate, the family should be reassured that fluctuations
in symptom levels can occur during treatment before an acceptable
level of remission is reached. Although treatment works for most
patients to reduce the burden of panic disorder, patients may continue
to have lingering symptoms, including occasional panic attacks and
residual avoidance. Other problems, such as a depressive episode,
could also develop and require specific attention.
Relapse following treatment cessation is also possible. Patients
should be instructed that panic disorder may recur and that, if
it does, it is important to initiate treatment quickly to reduce
the likelihood of complications such as agoraphobic avoidance (63).
The patient should be assured that he or she is welcome to contact
the psychiatrist and that resuming treatment almost always results
in improvement.
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B. Choosing a Treatment Setting
The treatment of panic disorder
is generally conducted entirely on an outpatient basis, and the
condition by itself rarely warrants hospitalization. Occasionally,
the first contact between patient and psychiatrist occurs in the
emergency department or the hospital when the patient has been admitted in
the midst of an acute panic episode. The patient may even be admitted
by emergency department staff to rule out myocardial infarction
or other serious general medical events. In such individuals, the
psychiatrist may be able to make the diagnosis of panic disorder
and initiate treatment once other general medical conditions have
been ruled out. Because panic disorder frequently co-occurs with
mood disorders and may elevate the risk of suicide attempts, it
may also be necessary to hospitalize the patient with panic disorder
when suicidal ideation is of clinical concern. Similarly, patients with
panic disorder frequently have co-occurring substance use disorders,
which can occasionally require inpatient detoxification. Under such
circumstances, the treatment of panic disorder can be initiated
in the hospital along with treatment of the disorder that prompted
hospitalization. Rarely, hospitalization or partial hospitalization
is required in very severe cases of panic disorder with agoraphobia
when administration of outpatient treatment has been ineffective
or is impractical. For example, a housebound patient may require
more intensive and closely supervised treatment in the initial phase
of therapy than that provided by outpatient care (64, 65).
Home visits are another option for severely agoraphobic patients
who are limited in their ability to travel or leave the house.
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C. Choosing an Initial Treatment
Modality
A range of specific psychosocial and pharmacological interventions
have proven benefits in treating panic disorder. The use of an SSRI
(66–87), SNRI (88, 89),
TCA (70, 72, 79, 90–112),
benzodiazepine (appropriate as a monotherapy only in the absence
of a co-occurring mood disorder) (104, 113–132), or
CBT (67, 111, 133–144)
as the initial treatment for panic disorder is strongly supported
by demonstrated efficacy in numerous controlled trials. A particular
form of psychodynamic psychotherapy called panic-focused psychodynamic
psychotherapy (145) has also been shown to be effective
in a randomized controlled trial (146), suggesting
that under certain circumstances (e.g., patient preference for a
dynamically oriented therapy), PFPP could be offered as an initial
treatment. Other psychosocial treatments for patients with panic
disorder have either been found equivalent to placebo conditions (e.g.,
EMDR), have proven inferior to standard treatments (e.g., supportive
psychotherapy [147]), or have not
been formally tested in controlled studies (e.g., certain forms
of psychodynamic psychotherapy).
There is insufficient evidence to recommend any proven efficacious
psychosocial or pharmacological intervention over another or to
recommend a combination of treatments over monotherapy. Considerations
that guide the choice of an initial treatment modality include patient
preference, the risks and benefits of the two modalities for the
particular patient, the patient's past treatment history,
the presence of co-occurring general medical and other psychiatric
conditions, cost, and treatment availability. Advantages of pharmacotherapy include
ready availability and the need for less effort by the patient for
treatment to take effect. Disadvantages include risks of adverse
effects, with roughly 10%–20% of patients
in clinical trials of common medications for panic disorder specifically
citing medication side effects as a reason for dropping out of the
trial. Discontinuation symptoms can be an additional disadvantage,
necessitating that patients taper medication slowly if a decision
is made to stop medication. Costs of medications vary and are affected
by the choice and dose of the agent, the availability of generic
preparations, the duration of treatment, requirements for additional
pharmacotherapy or psychosocial treatment, and the cost of treating
medication-related side effects. From the standpoint of patient preference, many
patients do not wish to take medications (148), and they
may perceive a psychosocial treatment as a more favorable option.
For example, studies of CBT have shown that patients may prefer
it to pharmacotherapy (111, 149). On the other
hand, psychotherapy requires considerable time and discipline on
the part of the patient to confront feared situations or perform
the "homework" associated with treatment. With
CBT, approximately 10%–30% of patients
have been found unwilling or unable to do this (133–135, 137).
Patients who are reluctant to invest time, effort, and short-term
increases in anxiety in exchange for possible longer-term resolution
of symptoms may not desire, and are less likely to benefit from,
psychosocial treatment. In terms of psychosocial treatment costs,
contributory factors include the duration and frequency of treatment,
its administration in an individual or group setting, and any requirements
for additional psychosocial or pharmacological treatment. An additional
disadvantage of specialized psychotherapies is that they may not
be readily available to patients in some areas.
Combining psychotherapy and pharmacotherapy is intuitively
attractive and common in clinical practice. Several specific combination
treatments have been studied and shown to be effective for panic
disorder, including CBT (or exposure therapy) plus imipramine (91, 111, 150–155),
CBT plus paroxetine (69), exposure therapy plus fluvoxamine
(68), psychodynamic psychotherapy plus clomipramine
(156), and algorithm-based pharmacotherapy plus a collaborative
care intervention that included CBT (157–159).
With regard to the comparative efficacy of combined treatment
versus monotherapy, the most recent meta-analysis of randomized
controlled trials of treatments for panic disorder suggested a small
but significant advantage for the combination of antidepressants
plus psychotherapy over monotherapies in the acute phase of treatment
(160). However, combined treatment was no better than
psychotherapy alone in longer-term follow-up, although it was superior
to pharmacotherapy alone (160). In addition, some studies
have raised concerns about the possibility that simultaneously initiating benzodiazepines
(149, 161) or antidepressant medications (111)
with CBT may diminish the durability of response to CBT after all
treatments are withdrawn. These results, which are by no means definitive,
should be considered in treatment of patients who plan to pursue
CBT and are also contemplating starting medication.
Although combination treatment does not appear to be significantly
superior to standard monotherapies for most individuals with panic
disorder, psychiatrists and patients may choose this option for
a variety of individual circumstances. For example, many clinicians
combine pharmacotherapy to provide more immediate control of distressing
symptoms with psychosocial treatments intended to address symptoms over
the long term and reduce future need for medications.
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D. Evaluating Whether
the Treatment Is Working
After treatment is initiated, it is important to monitor change in
the patient's key symptom domains, such as frequency and
intensity of panic attacks, level of anticipatory anxiety, degree
of agoraphobic avoidance, and severity of interference and distress
related to panic disorder. Effective treatment should produce a
decrease in each of these domains, although some may change more
quickly than others (e.g., the frequency of panic attacks may decrease
before agoraphobic avoidance decreases). The pattern of symptom
resolution varies depending on the individual patient; for example,
some experience "sudden gains" in which they manifest
a significant decrement in symptoms in a brief period of time, whereas
others experience steady and gradual improvement over a period of
many weeks. As described earlier in Section II.A.7, rating scales
can be a useful adjunct to ongoing clinical assessment in evaluating
treatment outcome. The severity of co-occurring conditions also
should be assessed at regular intervals, as effective treatment
of panic disorder can influence co-occurring conditions.
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E. Determining If
and When to Change Treatment
Clinical trials suggest that many individuals do not respond, or
respond incompletely, to first-line treatments for panic disorder.
Whenever treatment response is unsatisfactory (e.g., inadequate
reduction of panic attacks, continued agoraphobic avoidance), the
psychiatrist should first consider the possible contribution of
the following factors: an underlying untreated medical illness,
interference by co-occurring general medical or psychiatric conditions
(including substance use), inadequate adherence to treatment recommendations,
problems in the therapeutic alliance, the presence of psychosocial stressors,
motivational factors (e.g., secondary gain that results from the
patient's panic disorder symptoms), and inability to tolerate
a particular treatment. These potential impediments to successful
treatment should be addressed as early as possible. With pharmacotherapy,
the dose of medication may also be an important consideration. Clinical
experience suggests that patients who do not respond after several
weeks at the lower therapeutic dose range may do better with a further
dose increase (i.e., to the highest tolerable level within accepted
dosage ranges), although this strategy has not been systematically
studied.
It is important for the psychiatrist to remember that patients
with panic disorder may have become accustomed to avoiding anxiety-
and panic-provoking situations and may resist treatments that focus
on eliminating this avoidance (e.g., CBT, exposure instructions
assigned as an adjunct to pharmacotherapy). Thus, the psychiatrist
should explore whether fearfulness is leading the patient to minimize
reporting the impact of avoidance or to accept functional limitations
resulting from avoidance. If such fears are an issue, the patient
can be encouraged to think through the costs and benefits of accepting
versus treating functional limitations.
Another important consideration is that many patients with
panic disorder have co-occurring depression. If the patient is in
a dysphoric state he or she may be hopeless about the possibility
of change. It is important to mitigate the effects of depression
on the patient's level of optimism about treatment options
(e.g., point out that depression may be affecting the patient's
perceptions and recommend trying something new even if the patient
is doubtful that it will work).
If response to treatment remains unsatisfactory, and if an adequate
trial has been attempted, it is appropriate for the psychiatrist
and the patient to consider a change. Although there is a lack of
evidence for what constitutes an adequate trial, it is important
to consider the usual time course of response to specific therapies.
For example, with CBT, the literature shows that improvement may
not plateau until 12 sessions of treatment have been completed.
With benzodiazepines, psychiatrists and patients often note some
reduction in panic within the first week of treatment, although
full blockade of panic attacks can take several weeks, particularly
as the dose is being titrated for the individual. With SSRIs, SNRIs,
and TCAs, reduction in panic attack frequency, anticipatory anxiety,
and avoidance may start within the first 3–4 weeks of treatment.
However, there is evidence that therapeutic response continues to
accrue with continued pharmacotherapy. For some patients and particularly
for those with a significant level of agoraphobic avoidance, full
remission of symptoms, including the complete cessation of panic
attacks, full resolution of anticipatory anxiety and agoraphobia,
and full return to functioning, may take up to 6 months or longer (72)
(including 4–6 weeks at the highest comfortably tolerated
dose). Thus, many experts recommend waiting at least 6 weeks from
initiation of antidepressant treatment, with at least 2 of those
weeks at full dose, before deciding whether more intensive, additional,
or alternative treatments are warranted. When a patient's
symptoms are severe, however, it is often not feasible to wait that
long. Consequently, the approach and timing of treatment changes
must be individualized to the patient's symptoms and circumstances.
Decisions about whether to
make changes will also depend on the following factors: level of
partial response (e.g., if virtually no benefits are apparent, a
change should almost certainly be undertaken; if slow but steady
progress is apparent, the psychiatrist and patient may decide to
continue the current trial for a brief period then reassess); the
palatability and feasibility of other treatment options (e.g., a
patient who does not respond to psychosocial treatment might benefit from
pharmacotherapy, but some patients are unwilling to take medication;
a patient who does not respond to medication might benefit from
psychosocial treatment, but psychosocial treatment may not be feasible
because the patient cannot commit the time for weekly sessions and
homework with CBT); and the level of symptoms and impairment the patient
is willing to accept (e.g., the patient may still avoid some situations
but may not be motivated to overcome those fears at present; the
patient may still experience occasional panic attacks but may view
this as tolerable and not wish to pursue further treatment to eliminate
remaining symptoms). However, persistent significant symptoms of
panic disorder despite a lengthy course of a particular treatment
should trigger a reassessment of the treatment plan, including possible consultation.
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F. Approaches to
Try When a First-Line Treatment Is Unsuccessful
If the fundamental clinical issues described in the previous section
have been addressed and it is determined that a change in treatment
approach is desirable, the psychiatrist and patient have two basic
options. The first option is to augment the
current treatment by adding another agent (in the case of pharmacotherapy)
or another modality. Alternatively, the psychiatrist and patient
may decide to switch to a different
medication or therapeutic modality.
Decisions about how to address treatment resistance are likely
to be highly individualized and based on clinical judgment, since
few studies have tested the effects of specific augmentation and
switching strategies. Decisions, however, can be informed by the
extent of the patient's response and by the evidence that
supports specific treatments as initial monotherapies. In general,
if one first-line treatment has failed, adding or switching to another
first-line treatment is recommended. Augmentation is also a reasonable
approach if some significant benefits were observed with the original treatment.
For instance, for a patient who had partial response to an SSRI
or SNRI, the psychiatrist may consider adding a benzodiazepine or
a course of CBT. On the other hand, if the original treatment did
not provide any alleviation of
the patient's symptoms, a switch in treatment may be more useful.
For example, patients who do not respond to standard pharmacotherapies
may respond to CBT (162–164),
whereas those who do not respond to CBT or exposure therapy may benefit
from pharmacotherapy (165, 166). If a
patient's first unsuccessful treatment is with an SSRI
or an SNRI, a recommended approach is to switch to a different SSRI
or SNRI. If the patient's symptoms do not respond to two
different SSRIs or SNRIs, switching to or adding other classes of
medication that have demonstrated efficacy for panic disorder (e.g., TCAs,
benzodiazepines) may be considered. When switching between antidepressants,
psychiatrists will often cross-titrate (e.g., decreasing the dose
of the original medication over 1–2 weeks while gradually
increasing the dose of the new medication). Adding or switching
to CBT may also be considered at any point when a patient shows
incomplete or nonresponse to standard pharmacotherapy.
If the above treatment options, which have the highest levels
of empirical support, have been unsuccessful, other options with
some empirical support can be considered. Monoamine oxidase inhibitors
are widely regarded as effective for panic disorder. Although the
safety profile of MAOIs limits their use, they have demonstrated
efficacy in older studies that included patients with probable panic
disorder. Thus, MAOIs may be considered if the psychiatrist is experienced
in managing these agents and if the patient is willing to adhere
to a low-tyramine diet and to restrictions on the use of certain
other medications. In addition, before switching to an MAOI, the
psychiatrist should discontinue other antidepressant medications
and allow a sufficient washout period (usually at least 2 weeks
for most antidepressants and longer for those with very long half-lives
such as fluoxetine) before treatment with the MAOI is initiated.
The effectiveness of PFPP is supported by positive findings of a
randomized controlled trial (146), making it another
reasonable choice to consider for patients who prefer nonmedication
treatments or for those who have not responded to other treatments.
Other forms of psychodynamic psychotherapy have not been formally
tested but are supported by case report evidence and clinical experience;
these forms of treatment also may be considered as options for patients
who have not responded to other treatments for panic disorder.
Other treatments with even more limited evidence also may
be considered as monotherapies or augmentation agents under some
circumstances (e.g., several other treatments have been unsuccessful;
the patient cannot tolerate other treatments). Mirtazapine and gabapentin
have modest evidence bases that support their use in some individuals
with panic disorder. Although beta-blockers have generally been found
ineffective as monotherapy for panic disorder, there is some preliminary
support for the use of pindolol as an augmentation agent to enhance
antidepressant response. Antipsychotics are not recommended because
of limited evidence for their efficacy and concerns about side effects.
However, there is very preliminary evidence for the efficacy of
second-generation antipsychotics such as olanzapine and adjunctive risperidone,
so these agents could be considered for patients with very severe,
treatment-resistant panic disorder. Some clinical experience suggests
that patient support groups may be helpful, adjunctive to other
treatment. With the exception of group CBT, which has demonstrated
efficacy in controlled trials, other forms of group therapy are
unstudied and have unclear efficacy. Eye movement desensitization
and reprocessing and couples and family therapy have been shown
to be ineffective in the treatment of panic disorder.
Sections II.G and II.H provide
additional information on the second- and third-line psychotherapeutic
and pharmacological treatments described above, as well as for other
unproven treatments. Psychiatrists are encouraged to seek consultation
from experienced colleagues when developing treatment plans for
patients whose symptoms have been resistant to first-line treatments
for panic disorder.
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G. Specific Psychosocial Interventions
The following sections review psychosocial interventions that
have been formally evaluated for treatment of panic disorder, as
well as some treatments that have not been tested but are occasionally
utilized by patients with panic disorder. Psychosocial treatments
for panic disorder should be conducted by professionals with an
appropriate level of training and experience in the relevant approach.
Based on the current available evidence, CBT is the psychosocial
treatment that would be indicated most often for patients presenting
with panic disorder. The efficacy of CBT (including exposure therapy
alone) for panic disorder has been documented in numerous controlled
trials. CBT is effective when delivered individually or in a group
format. Individually administered PFPP also has demonstrated efficacy
for panic disorder, although research on this treatment is in earlier
stages and its evidence base is more limited. Panic-focused psychodynamic
psychotherapy may be indicated as an initial psychosocial treatment
for panic disorder in some circumstances (e.g., with a patient who
is motivated for and able to engage in this approach). Other psychosocial treatments
either have not been formally tested for panic disorder (e.g., certain
forms of psychodynamic psychotherapy) or have proven ineffective
or inferior to standard treatments (e.g., EMDR, emotion-focused
therapy).
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1. Cognitive-behavioral
therapy
The use of CBT for panic disorder is based on the assumption that
maladaptive patterns of cognition and behavior maintain panic disorder.
Cognitive-behavioral therapy generally targets these maintaining
factors and places less emphasis on determining the origins of panic
disorder for a particular patient. Cognitions hypothesized to maintain
panic disorder include catastrophic misinterpretations of physical
symptoms (e.g., the belief that palpitations signal an impending
heart attack) (for example, see references 167 and 168).
Therefore, many versions of CBT seek to identify and change mistaken beliefs
about physical symptoms and their consequences. The symptoms of
panic disorder and agoraphobia also have been conceptualized as
resulting from conditioning processes (for example, see references 169–171).
Consequently, many versions of CBT include techniques aimed at 1) weakening
or extinguishing learned associations between stimuli (both internal
and external) and panic and 2) creating opportunities for learning
and strengthening nonanxious responses. All forms of CBT conceptualize
avoidance behavior as a maintaining factor in panic disorder, either
because it prevents patients from disconfirming their anxious beliefs
or because it prevents habituation of fear responses. Thus, confronting feared
stimuli and situations is an essential part of CBT for panic disorder.
Most forms of panic-focused
CBT employ the following treatment components: psychoeducation,
self-monitoring, cognitive restructuring, exposure to fear cues,
modification of anxiety-maintaining behaviors, and relapse prevention.
In providing CBT, the clinician may opt to focus more on certain
treatment components than on others, depending on the patient's
symptom profile and response to different CBT techniques.
Panic-focused CBT is generally administered in 10–15 weekly
sessions (172). Therapy usually begins with one or more
psychoeducation sessions that serve to identify the patient's
symptoms and areas of impairment, provide accurate information about
the nature and purpose of anxiety and fear, conceptualize the patient's
experiences in terms of the CBT model, and outline a rationale and
plan for treatment. Information gathering and education are done
in an interactive manner, with a continual focus on applying the
CBT model to a patient's particular symptoms and situations.
The CBT therapist adopts a collaborative stance, and the educational material
sets the stage for the therapist and patient to develop a shared
understanding of the patient's problems. A major goal of
psychoeducation for panic disorder is conveying that panic symptoms
result from the body's natural fear response and are not
dangerous. Reading material that reinforces the concepts introduced
in the psychoeducation sessions is usually assigned for homework
(see the Appendix for titles of patient workbooks that include these
materials).
Self-monitoring is another core component of CBT. Patients
monitor their panic attacks using techniques such as keeping a daily
diary. They are asked to record the date, time, location, and any
perceived triggers of the panic attack. They also may be asked to
record the physical symptoms, anxious thoughts, and behavioral responses
that occurred during the attack. Patients are informed that this
will help to assess the frequency and nature of their panic attacks
and to provide data regarding the relationship of panic symptoms
to potential triggers.
Another component of CBT is exposure to fear cues. Patients
with panic disorder can experience panic attacks in response to
internal and external cues (169). The most common internal
fear cues are bodily sensations (e.g., heart racing, dizziness,
shortness of breath). Common external fear cues include situations
in which having a panic attack would be embarrassing or in which
escape would be difficult (e.g., public places, enclosed spaces).
For most patients, exposure to both internal and external fear
cues is necessary for remission of panic symptoms to occur. Exposure
proves to be the most challenging and often the most potent component
of CBT. Additional effort on the part of the clinician is often
required to motivate the patient to initiate and persevere with
increasingly difficult exposure practices. Internal fear cues are
addressed through interoceptive exposure. Interoceptive exposure
involves exposing the patient to feared bodily sensations in a systematic
way, until he or she no longer responds fearfully to those sensations.
Feared bodily sensations are provoked using a series of exercises
such as running in place (to induce heart pounding), spinning in
a chair or while standing up (to induce dizziness), and hyperventilation
or breathing through a straw (to induce light-headedness or shortness
of breath). The CBT therapist first assesses which of these exercises
produce symptoms that are anxiety provoking for the patient, and
then instructs the patient to perform those exercises repeatedly
until the patient is no longer afraid of the exercises or the symptoms
that result. External fear cues are targeted through situational
exposure, which involves confronting situations or activities that
commonly provoke fear. Situational exposure can include a wide variety
of exercises such as driving on a highway, riding in an elevator,
or visiting a grocery store or shopping mall.
The process of conducting exposures to internal and external
fear cues is systematic. The therapist first works with the patient
to identify a hierarchy of fear-evoking situations. The degree of
anxiety elicited in each of these situations is graded on a 0–10
scale, and several situations that evoke anxiety at each level are
documented. The patient is then asked to confront the symptom or
situation, usually beginning at the low end of the hierarchy on
a regular (usually daily) basis until the fear has attenuated. The
symptom or situation that arouses the next level of anxiety is then
targeted. Interoceptive exposures are usually conducted in the therapist's
office and at home in naturalistic situations. Situational exposures
are best carried out in the actual situation(s). Patients typically
conduct situational exposures on their own for homework; however,
some CBT therapists will accompany patients to locations for situational
exposures. Whereas the usual practice is to start with the least
anxiety-provoking exercises and move up in intensity, patients who
are motivated to treat their panic disorder more aggressively can
begin exposure treatment with exercises that are more challenging
(i.e., those near the top of their hierarchy) with the notion that
this approach may help them achieve their treatment goals more quickly
(54). Patients also are encouraged to combine interoceptive
and situational exposure as they progress through treatment (e.g.,
deliberately hyperventilating while driving) in order to learn that
they can enter feared situations and cope with them even while experiencing
intense physical sensations.
Most CBT practitioners include cognitive restructuring techniques
as one element of treatment, although some CBT therapists and some
studies (for example, see reference 140) have questioned
whether cognitive restructuring provides benefits beyond those obtained
with exposure. When used as a CBT component, cognitive restructuring
focuses on identifying and countering erroneous beliefs that contribute
to panic disorder. Patients with panic disorder commonly interpret
panic symptoms in a catastrophic manner (e.g., as signs of an impending
heart attack or fainting spell). They also typically underestimate
their ability to cope with panic attacks (42). In CBT,
the therapist encourages the patient to recognize the thoughts that
occur during panic attacks and to consider the evidence for and
against these thoughts. When erroneous or exaggerated beliefs are
identified, the CBT therapist and patient work together to review
the evidence and generate a more realistic appraisal of the situation.
The skill of countering anxious thoughts and generating more evidence-based thoughts
is reinforced throughout treatment with in-session practice and
homework assignments. Many CBT therapists integrate cognitive and
exposure procedures. This integration focuses on using the exposure
to fear cues as a vehicle for helping the patient acquire corrective
threat-disconfirming information (e.g., "even though I
felt anxious and dizzy while at the grocery store, I did not faint").
Modification of anxiety-maintaining "safety behaviors" is
another common goal of CBT. Common safety behaviors include carrying
medication bottles, establishing exit routes, and checking the locations
of hospitals (173). Safety behaviors often provide
the patient with an immediate feeling of security; however, within
CBT they are conceptualized as maintaining anxiety in the longer
term. Safety behaviors may reinforce the notion that everyday situations
are inherently dangerous, prevent patients from disconfirming their
threat-laden beliefs, and interfere with deriving maximum benefit from
exposure practices (174). Fading and eventual elimination
of safety behaviors is therefore a goal of most CBT protocols.
Some CBT protocols also teach slow, diaphragmatic breathing
as a skill that patients can use to decrease anxiety and interrupt
the cycle of panic (for example, see reference 111). Although
the evidence suggests that breathing retraining is likely not a
necessary component of treatment (175), it is still often
included in CBT for panic disorder and may be a useful anxiety-reduction
tool for some patients.
Cognitive-behavioral therapy for panic disorder is often provided
individually, but there is evidence that group treatments may be
equally effective (137, 142, 176–179).
Exposure treatments for patients with agoraphobia also are efficacious
when conducted in a group format (178). The inclusion
of the spouse or significant other in treatment can be helpful,
especially if the significant other is educated about the CBT model
of panic disorder and can provide support and encouragement when
the patient confronts feared situations (180, 181).
Because CBT is not widely available in some communities, some
patients may have to travel a great distance to see a clinician
who is proficient in CBT, or they may not have access to CBT at
all. Some evidence suggests that high-density therapy (i.e., several
hours of therapy within a few days) can be effective (182, 183),
and this approach may be useful for patients who cannot attend a
standard course of weekly sessions. One small waiting-list-controlled
study showed that telephone-based CBT was effective for patients
with severe agoraphobia who lived in rural areas (184).
Self-directed forms of CBT and exposure therapy that are guided
by a computer (often with minimal therapist contact via email or phone)
also have been shown to be effective in several controlled studies
(185, 186). Studies that directly compare
live CBT to largely computer-guided formats have generally shown
both to be effective, but in some studies live CBT produced larger
effects and was associated with lower dropout rates (139, 186–189).
When available, computer-guided CBT may be a useful option for patients
with panic disorder who do not have ready access to a specialist.
The available data suggest that the benefits of a short-term course
of CBT are long-lasting (for example, see reference 160).
However, once patients have achieved a satisfactory reduction in
symptoms and impairment, the focus of CBT shifts, and development
of a specific relapse prevention plan becomes an integral part of
treatment. The therapist normalizes fluctuations in anxiety and
anticipates that the patient may experience periods of increased
anxiety (including occasional panic attacks) in the future. The
therapist and patient collaborate to anticipate potential triggers
for these periods of increased anxiety (e.g., work stress, moving
to an unfamiliar place) and to develop an individualized relapse
prevention plan that the patient can follow if symptoms recur. This plan
typically involves a return to more intensive practice of CBT skills
that were previously helpful such as exposure and cognitive restructuring.
If symptoms do not improve with the implementation of the practice
plan, the therapist and patient can consider the option of "booster
sessions" (i.e., a short course of CBT to help the patient
reinstitute skills that were previously helpful). If efforts to
boost response are unsuccessful, the psychiatrist should consider
trying a different treatment modality or referring the patient to
another qualified professional.
There is little evidence to suggest that CBT and commonly
prescribed medications for panic disorder either enhance or counteract
one another in the acute term. One randomized controlled trial found
that fluvoxamine plus exposure therapy was superior to either alone
in treatment of panic disorder with moderate to severe agoraphobia
(68); however, this result has not been replicated.
In contrast, another study found that, 6 months after treatments
were withdrawn, patients who responded to a combination of imipramine
and CBT for panic disorder displayed poorer maintenance of response
than those who received CBT alone or CBT plus placebo (111).
This finding raises some concern that simultaneously initiating
medication and CBT may negatively affect the durability of the effects
of CBT after treatments are withdrawn. This topic requires further
study before firm conclusions can be drawn. Concern also exists
about possible decreases in the efficacy of CBT if combined with benzodiazepines,
although there is a dearth of systematic empirical data on this
topic (190). One large randomized controlled trial
showed that although adding alprazolam to exposure therapy marginally
enhanced gains during acute treatment, patients who received the
combination relapsed more after treatment withdrawal compared to
those who received exposure plus placebo (149). Another
small study showed that patients taking benzodiazepines had poorer memory
for the educational material presented in CBT than patients who
were taking no medications (161). Clinical experience
suggests that p.r.n. ("as needed") use of benzodiazepines
to block anxiety symptoms can be difficult to reconcile with certain
components of CBT, and many CBT therapists discourage p.r.n. benzodiazepine
use as soon as the patient has developed other anxiety management
skills.
Cognitive-behavioral therapy for panic disorder has been shown
to be effective in treating not only the targeted panic disorder
but also in reducing the rates and severity of some co-occurring
conditions (191–194).
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2. Psychodynamic
psychotherapy
The goal of psychodynamic psychotherapy is to achieve remission
of panic disorder symptoms through a therapeutic process that encourages
exploration of feelings and past and present traumatic experiences.
The core principles of psychodynamic psychotherapy are 1) the appreciation
that much of mental life is unconscious, 2) childhood experiences
in concert with genetic and constitutional factors shape adult personality,
and 3) individual symptoms and behaviors may serve multiple functions
(195).
Many studies suggest that acute stressors, or "life
events," occur just prior to panic disorder onset (196–198).
According to psychodynamic theory, the psychological meaning of
these events as well as symptoms, behaviors, and coping styles are determined
by complex forces that may be unavailable to the patient's
conscious awareness (199–201).
In patients with panic disorder, one of the goals of psychodynamic
psychotherapy is to uncover and understand the thoughts and feelings
associated with panic symptoms as well as the unconscious psychological
meanings of these panic symptoms, issues that are theorized to be
related to separation, autonomy, self-esteem, anger, or aggression.
Understanding of transference and interpretation are used to elucidate
these issues as well as related interpersonal conflicts. In addition,
the therapist attempts to identify and alter core conflicts in order to
reduce vulnerability to future panic symptoms (145).
Given the highly individualized nature of these thoughts, feelings, and
conflicts, the length and intensity of most psychodynamic psychotherapy
also tends to be individualized.
In psychodynamic psychotherapy, symptom relief or resolution
is theorized to result from emotional growth and understanding of
the various developmental and psychological issues that relate to
the patient's symptoms. Examples include both conscious
and unconscious problems of self-esteem and self-cohesion, unresolved
developmental trauma, and psychic conflict (e.g., unacceptable impulses,
unrealistic or harsh issues of self-esteem and conscience, unadaptive
psychological defenses). The therapist places the current symptoms
in the context of the patient's life history and current
realities. The therapist-patient relationship is often used as a
vehicle to achieve insightful awareness by bringing the unconscious
into consciousness, as well as to facilitate intrapsychic growth.
Because psychodynamic therapies are rooted in various psychoanalytic
and/or psychodynamic theoretical models, there are a variety
of methods for conducting psychodynamic psychotherapy.
Panic-focused psychodynamic psychotherapy is a twice weekly,
12-week manualized treatment program developed by Milrod and associates
(145) that has been tested in a randomized controlled
trial (146). It focuses on the underlying psychological
meaning of panic symptoms and on current social and emotional functioning.
Panic-focused psychodynamic psychotherapy is based on the postulate
that panic symptoms carry a specific emotional significance that
the patient must confront before remission of the panic symptoms
can occur. According to this theoretical model, patients with panic
disorder are conceptualized as having difficulty separating from
important attachment figures and perceiving themselves as autonomous,
which is thought to motivate agoraphobic avoidance. The combination
of perceiving their environment and relationships as overly dangerous
and themselves as inadequate and lacking autonomy triggers high
levels of anxiety that perpetuate panic and agoraphobic avoidance.
Panic symptoms in turn are thought to reinforce conflicted interpersonal
relationships in which the patient feels excessively dependent on
significant others and frightened of losing them. Panic-focused psychodynamic
psychotherapy focuses on the transference as a mutative therapeutic
agent and does not require behavioral exposure to agoraphobic situations.
It helps patients to confront the emotional significance of their
physical symptoms and recognize that their fears of upcoming catastrophe
reflect an internal emotional state rather than reality. Through
these techniques, PFPP encourages patients to function more autonomously
and may help patients with panic disorder to achieve a greater sense
of personal efficacy, yielding improved function and symptomatic
relief.
Compared to PFPP, other approaches to psychodynamic psychotherapy
often have a wider focus on other psychological and interpersonal
issues in the patient's life. These alternative approaches
have not been the subject of rigorous research studies. Consequently,
evidence for the use of other psychodynamic psychotherapy approaches
in panic disorder is limited to case reports and opinions of psychodynamic psychotherapy
experts. No studies have compared the efficacy of the different
psychodynamic psychotherapy approaches or have compared psychodynamic
psychotherapy with other psychosocial treatments in patients with
panic disorder.
As with all psychiatric treatments, psychodynamic psychotherapy
(including PFPP) should be conducted by appropriately trained therapists,
and patients need to understand the rationale, goals, and potential
risks and benefits of the treatment. The exploration of memories
and important conflicted relationships and the surfacing of unconscious
material may sometimes be associated with powerful affects and transient
upsets in the therapeutic and other relationships. These occurrences
tend to decline in both frequency and intensity as the patient experiences
how they relate to and help resolve the symptoms and problems that
brought the patient to treatment.
Many patients with panic disorder have complicating co-occurring
Axis I and/or Axis II conditions. The broad focus of some
forms of psychodynamic psychotherapy may be useful in reducing symptoms
or maladaptive behaviors in these associated conditions. For example,
some preliminary data showed that PFPP demonstrated superiority
to applied relaxation therapy for patients with Cluster C personality
disorders, compared to patients without Cluster C personality disorders
(202).
Although evidence is limited, psychodynamic techniques have
been used in combination with pharmacotherapies or with elements
of CBT (145, 203, 204). For
example, patients with agoraphobic avoidance may be encouraged to
expose themselves to frightening situations and explore the feelings that
the exposure aroused to gain a deeper understanding of the conflicts
surrounding feared situations. In practice, psychodynamic therapies
are often used adjunctively with medication to assist in the resolution
of the panic symptoms (204, 205).
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3. Supportive psychotherapy
The available evidence suggests that supportive psychotherapy
is inferior to standard treatments for panic disorder. One controlled
study compared the efficacy of emotion-focused therapy, CBT, imipramine,
and pill placebo in patients with panic disorder (147).
Emotion-focused therapy was described as a short-term psychotherapy
that involved empathic listening and supportive strategies. Emotion-focused
psychotherapy was based on the theory that unrecognized emotions
(typically triggered by interpersonal situations) trigger panic
attacks; therefore, patients were encouraged to explore and process
their emotional reactions with the aim of resolving panic symptoms.
Results suggested that emotion-focused psychotherapy was less effective
than CBT and imipramine in treatment of panic disorder and that its
effect was approximately equivalent to that of placebo. Therefore,
emotion-focused therapy and other supportive psychotherapies that
resemble it cannot be recommended as treatments for panic disorder.
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4. Eye movement desensitization
and reprocessing
Eye movement desensitization and reprocessing was originally
developed as a treatment for posttraumatic stress disorder (206),
but it has been studied as a possible treatment for panic disorder.
Eye movement desensitization and reprocessing involves reprocessing
distressing memories while engaging in guided eye movement. When
applied to panic disorder, EMDR targets distressing memories such
as the memory of the first panic attack and life events that the
patient associates with panic disorder (207).
Empirical data on the use of EMDR in treating panic disorder
are limited. In one trial, six sessions of EMDR were superior to
a waiting-list control at posttreatment; however, the investigators
questioned the clinical significance of the treatment's
effect because very few patients who received EMDR showed substantial
functional recovery at 3-month follow-up (207). Another
study found EMDR to be equivalent in its effects to a credible attention-placebo
control (208). Eye movement desensitization and reprocessing
therefore cannot be recommended as a treatment for panic disorder
at this time.
Clinical experience suggests that possible benefits of a group format
for treating panic disorder include 1) decreasing shame and stigma
by providing experiences with others who have similar symptoms and
difficulties; 2) providing opportunities for modeling, inspiration,
and reinforcement by other group members; and 3) providing a naturally
occurring exposure environment for patients who fear having panic
symptoms in social situations. Most approaches to group therapy
have not been empirically tested for panic disorder. However, group CBT
for panic disorder has been shown to be effective in controlled
studies and therefore can be recommended with confidence as a treatment
for panic disorder (137, 176–179).
When considering a patient for inclusion in a CBT group, the therapist
should consider the severity of the patient's panic disorder, co-occurring
disorders, level of insight, interpersonal skills, and the patient's
preference for a group versus individual format.
There is limited evidence from a small uncontrolled trial for
the effectiveness of group mindfulness-based stress reduction for
patients with panic disorder (209, 210).
This modality includes training in meditation and relaxation strategies.
Other types of groups, such as medication support groups, may provide
useful adjunctive experiences for patients with panic disorder but
have not been tested empirically.
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6. Couples and family
therapy
Patients with panic disorder have symptoms that can disrupt day-to-day
patterns of relationships and may place a family member in a caretaker
or rescuer role. Increased dependency needs of patients with panic
disorder may lead to frustration in family members, and relationships
may be jeopardized. Results are mixed with regard to whether panic
disorder is associated with increased incidence of relationship
dysfunction or whether relationship dysfunction affects outcome
of standard treatments for panic disorder (180).
The scant available literature
suggests that marital therapy alone is less effective than established
treatments in relieving panic symptoms (211). Based
on the available data, couples or family therapy alone cannot be
recommended as a treatment for panic disorder. In contrast, partner-assisted
exposure therapy for panic disorder has been shown to reduce symptoms
of panic disorder in several studies (180). Other studies have
documented benefits of including patients' significant others
in group-based CBT (177, 212, 213)
and of adding couples-based communication training to exposure treatment (214).
Therefore, including a significant other in CBT or exposure-based
treatment may be a useful approach for some patients.
When pursuing other treatments for panic disorder (e.g., pharmacotherapy),
educating significant others about the nature of the disorder and
enlisting them to improve treatment adherence may also be helpful.
However, no empirical studies of involving partners or family members
in other types of treatment have been published.
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7. Patient support
groups
Patient support groups may be helpful for some patients with panic
disorder. Patients who participate in support groups have the opportunity
to learn that they are not unique in experiencing panic attacks
and to share ways of coping with the illness. Family members of
patients with panic disorder also may benefit from the educational
aspects of patient support groups. In deciding to refer a patient
or family member to a support group, it is important that the psychiatrist
obtain information about the nature of the group and the credentials
of its leader(s). Support groups are not a substitute for effective treatment;
rather, they are complementary.
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8. Complementary
and alternative treatments
A review of research on a variety of self-help and alternative treatments
for anxiety disorders concluded that there was no evidence for efficacy
of most of these treatments for panic disorder (215).
Treatments evaluated included natural products (e.g., kava, St.
John's wort, inositol), other physical treatments (e.g.,
acupuncture, massage), and lifestyle treatments (e.g., yoga, relaxation).
Most of the treatments had never been formally tested in patients
with panic disorder. Very preliminary support is available for the
efficacy of the glucose isomer inositol in treatment of panic disorder;
however, inositol is rarely used clinically, and more extensive clinical
research is necessary to establish its efficacy (216, 217).
Evidence of efficacy has also been found for relaxation training
(215). Although one controlled study found applied relaxation
to be as effective as CBT and exposure therapy (218),
a recent meta-analysis suggested that relaxation training is less
effective than CBT for patients with panic disorder (219).
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H. Specific Pharmacological Interventions
Because medications from four
classesSSRIs, SNRIs, TCAs, and benzodiazepinesare
roughly comparable in efficacy, the decision regarding which medication
to choose for panic disorder mainly involves considerations of side
effects, cost, prior treatment history, the presence of co-occurring
general medical and other psychiatric conditions, and the strength
of the evidence base for the particular medication in treatment
of panic disorder. Medication choice can also be influenced by pharmacological
properties such as medication half-life, drug metabolism (e.g.,
effects of cytochrome P450 isoenzymes), and the potential for drug
interactions. These latter factors are particularly important when treating
older adults and individuals taking multiple medications.
Selective serotonin reuptake inhibitors or SNRIs are likely to
be the best choice of pharmacotherapy for many patients with panic
disorder, though SSRIs have a larger evidence base and are more
likely to be chosen as a first-line treatment. Although SSRIs and
SNRIs do carry a risk of sexual side effects, they lack