0
1
+

Establish a therapeutic alliance.

  • Give careful attention to the patient's preferences and concerns with regard to treatment.

  • Provide education about panic disorder and its treatment in language that is readily understandable to the patient.

  • Support the patient through phases of treatment that may be anxiety provoking (e.g., anticipating medication side effects, confronting agoraphobic situations).

+

Perform the psychiatric assessment.

  • Evaluation generally includes the components described in Table 1.

  • Assess clinical features that may influence treatment planning, including the presence of agoraphobia and the extent of situational fear and avoidance; the presence of co-occurring psychiatric conditions, including substance use; and the presence of general medical conditions.

  • Consider if the patient's panic attacks are best diagnosed as a symptom of DSM-IV-TR panic disorder or whether they are related to substance use or a general medical condition (e.g., thyroid disease) or a side effect of medications prescribed to treat such conditions (e.g., oral corticosteroids).

  • Note that panic disorder may also co-occur with many general medical conditions (Table 2) and with many psychiatric disorders, especially personality disorders, substance use disorders, and mood disorders.

+
Table Reference Number
Table 1. Components of a Psychiatric Evaluation for Patients With Panic Disorder
+
Table Reference Number
Table 2. General Medical Conditions More Prevalent in Patients With Panic Disorder Than in the General Population
+

Tailor the treatment plan for the individual patient.

  • Take into account the nature of the individual patient's symptoms as well as symptom frequency, symptom triggers, and co-occurring conditions.

  • To better assess symptoms, consider having the patient monitor them, for example, by keeping a diary. A diary may also help with ongoing assessment of the patient's psychiatric status and response to treatment.

  • Consider the role of ethnicity and cultural factors in the patient's presentation—for example, by using the DSM-IV-TR Outline on Cultural Formulation—and tailor treatment accordingly.

+

Evaluate the safety of the patient.

  • Carefully assess suicide risk (Table 3). 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.

  • Decide whether the patient can safely be treated as an outpatient, or whether hospitalization is indicated.

+
Table Reference Number
Table 3. Components of a Suicide Risk Assessment for Patients With Panic Disorder
+

Evaluate types and severity of functional impairment.

  • Consider the impact of panic disorder on the patient's functioning in domains such as work, school, family, social relationships, and leisure activities.

  • Aim to minimize impairment in these domains through treatment.

+

Establish treatment goals.

  • 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.

  • Treat co-occurring psychiatric disorders when they are present.

+

Monitor the patient's psychiatric status.

  • Monitor all symptoms originally presented by the patient.

  • Understand that symptoms may resolve in stages (e.g., panic attacks may remit before agoraphobic avoidance does) and that new symptoms may emerge that were not initially noted.

  • Consider using rating scales to help monitor the patient's status at each session.

+

Provide education to the patient and, when appropriate, to the family.

  • Provide education about the disorder and its treatment.

  • Inform the patient that panic attacks are not life-threatening, are almost never acutely dangerous, are not uncommon, and will abate. This information and reassurance alone may relieve some symptoms.

  • Consider encouraging the patient to read educational books, pamphlets, and trusted web sites. Useful resources are listed in the appendix of the full-text practice guideline.

  • When appropriate, also provide education to the family. This may include discussion of how changes in the patient's status can impact the family system, and how responses of family members can help or hinder treatment.

  • Promote healthy behaviors such as exercise; sleep hygiene; and decreased use of caffeine, tobacco, alcohol, and other potentially deleterious substances.

+

Coordinate the patient's care with other clinicians.

  • Communicate with other health care professionals who are evaluating or treating the patient.

  • Ensure that a general medical evaluation is done (either by the psychiatrist or by another health care professional) to rule out medical causes of panic symptoms. Extensive or specialized testing for medical causes of panic symptoms is usually not indicated but may be conducted on the basis of individual characteristics of the patient.

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Enhance treatment adherence.

  • Whenever possible, assess and acknowledge potential barriers to treatment adherence (Table 4) and work collaboratively with the patient to minimize their influence.

  • Encourage the patient to articulate his or her fears about treatment.

  • Educate the patient about when to expect improvement so that treatment is not prematurely abandoned.

  • Encourage the patient to raise concerns or questions, including by telephone if between visits.

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Table Reference Number
Table 4. Factors That May Contribute to Treatment Nonadherence
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Work with the patient to address early signs of relapse.

  • Reassure the patient that symptoms can fluctuate during treatment before remission is attained.

  • After remission, provide the patient a plan for responding to symptoms that linger or recur.

Table Reference Number
Table 1. Components of a Psychiatric Evaluation for Patients With Panic Disorder
Table Reference Number
Table 2. General Medical Conditions More Prevalent in Patients With Panic Disorder Than in the General Population
Table Reference Number
Table 3. Components of a Suicide Risk Assessment for Patients With Panic Disorder
Table Reference Number
Table 4. Factors That May Contribute to Treatment Nonadherence

References

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