0
1
+

Stabilize the medication dose.

  • Table 8 describes usual dosing for antidepressant and benzodiazepine pharmacotherapy for panic disorder. Important safety considerations are described in Table 9.

  • Because patients with panic disorder can be sensitive to medication side effects, low starting doses of SSRIs, SNRIs, and TCAs are recommended (approximately half of the starting doses given to depressed patients). 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.

  • Underdosing of antidepressants (i.e., starting low and never reaching full therapeutic doses) is common in the treatment of panic disorder and is a frequent source of partial response or nonresponse.

  • When benzodiazepines are prescribed, a regular dosing schedule rather than a PRN ("as needed") schedule is preferred for patients with panic disorder. The goal is to prevent panic attacks rather than reduce symptoms once the attack has already occurred.

  • Patients are typically seen every 1–2 weeks when first starting a medication, then every 2–4 weeks until the dose is stabilized. After the dose is stabilized and symptoms have decreased, patients will most likely require less frequent visits.

+
Table Reference Number
Table 8. Dosing of Antidepressants and Benzodiazepines for Panic Disorder
+
Table Reference Number
Table 9. Safety Considerations for Medications Used for Panic Disorder
+

Ensure that psychosocial treatments are conducted by professionals with an appropriate level of training and expertise.

  • CBT for panic disorder generally includes psychoeducation, self-monitoring, countering anxious beliefs, exposure to fear cues, modification of anxiety-maintaining behaviors, and relapse prevention. The clinician may opt to emphasize certain components depending on the patient's symptom profile and response to different CBT techniques. For most patients, exposure proves to be the most challenging but often the most potent component of CBT.

  • Exposure therapy focuses almost exclusively on systematic exposure to fear cues.

  • Possible benefits of group CBT include decreasing shame and stigma; providing opportunities for modeling, inspiration, and reinforcement; and providing an exposure environment for patients who fear having panic symptoms in social situations.

  • PFPP 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.

  • Other psychodynamic psychotherapies may focus more broadly on emotional and interpersonal issues.

+

Deliver psychosocial treatments for an appropriate period of time and in an appropriate format.

  • CBT is generally delivered in 10–15 weekly sessions. It can be successfully administered individually or in a group format.

  • Self-directed forms of CBT may be useful for patients who do not have ready access to a trained CBT therapist.

  • In research settings, PFPP has been administered on an individual basis twice weekly for 12 weeks.

+

Evaluate if the initial treatment is working.

  • Effective treatment should produce a decrease 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.

  • Some domains may change more quickly than others (e.g., the frequency of panic attacks may decrease before agoraphobic avoidance decreases). Furthermore, 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 in Section A ("Psychiatric Management"), 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 treatment of panic disorder can influence co-occurring conditions.

Table Reference Number
Table 8. Dosing of Antidepressants and Benzodiazepines for Panic Disorder
Table Reference Number
Table 9. Safety Considerations for Medications Used for Panic Disorder

References

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