What is the workup for severe panic disorder (PD) episodes?

From the Guidelines

A comprehensive workup for severe panic attacks should begin with a thorough medical evaluation to rule out physical causes, followed by a psychiatric assessment and treatment with a combination of medication and psychotherapy, prioritizing selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT) as first-line treatments. This approach is supported by recent guidelines, such as those suggested by the American Academy of Child and Adolescent Psychiatry 1, which recommend combination treatment (CBT and an SSRI) for patients with anxiety disorders, including panic disorder.

When evaluating patients with severe panic attacks, it is essential to consider the following key components:

• A thorough medical evaluation to rule out physical causes, including a complete physical examination, blood tests, and possibly an electrocardiogram to exclude cardiac issues that can mimic panic symptoms
• A psychiatric assessment focusing on symptom history, frequency, severity, triggers, and comorbid conditions like depression or substance use
• Treatment with a combination of medication and psychotherapy, with first-line medications including SSRIs such as sertraline, escitalopram, or paroxetine, and CBT as a highly effective therapeutic approach

Additional considerations include:

• The use of benzodiazepines like lorazepam for immediate relief, although with caution due to the risk of abuse and dependence 1
• Lifestyle modifications, such as regular exercise, adequate sleep, stress management techniques, and avoiding caffeine, alcohol, and nicotine, to reduce panic frequency
• The importance of cultural sensitivity and tailored treatment approaches, particularly when working with diverse patient populations 1

Overall, a comprehensive and multimodal approach to treating severe panic attacks is crucial, addressing both the neurochemical imbalances and psychological factors contributing to these episodes, and prioritizing evidence-based treatments like SSRIs and CBT 1.

From the FDA Drug Label

Panic Disorder Sertraline Hydrochloride Oral Concentrate is indicated for the treatment of panic disorder in adults, with or without agoraphobia, as defined in DSM-IV Panic disorder is characterized by the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks, and/or a significant change in behavior related to the attacks The efficacy of sertraline was established in three 10 to 12 week trials in adult panic disorder patients whose diagnoses corresponded to the DSM-III-R category of panic disorder

The workup for severe panic attacks may involve a diagnosis of Panic Disorder, which is characterized by recurrent unexpected panic attacks.

• Panic attacks are discrete periods of intense fear or discomfort that reach a peak within 10 minutes and include symptoms such as:
  • Palpitations or pounding heart
  • Sweating
  • Trembling or shaking
  • Shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Dizziness or lightheadedness
  • Fear of losing control or dying
• The diagnosis of Panic Disorder requires the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks, and/or a significant change in behavior related to the attacks 2.
• Sertraline is indicated for the treatment of Panic Disorder in adults, with or without agoraphobia, as defined in DSM-IV 2.

From the Research

Treatment Options for Severe Panic Attacks

• Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are commonly used to treat panic disorder, with SSRIs being the preferred first-line treatment due to their more favorable adverse effect profile 3
• Benzodiazepines can cause tolerance and dependence, but have a rapid onset of action, making them a viable option for severe panic attacks 4
• A meta-analysis found that SSRIs cause more adverse events than benzodiazepines in short-term treatment, including diaphoresis, fatigue, nausea, diarrhea, and insomnia 5
• Cognitive-behavioral therapy (CBT) is also a highly effective treatment for panic disorder, with strong evidence supporting its use 6

Medication Comparison

• A comparison of SSRIs and benzodiazepines found that SSRIs are associated with a delay in onset of therapeutic effect and can exacerbate anxiety and panic early in treatment, while benzodiazepines have a rapid onset of action but can cause tolerance and dependence 4
• Another study found that benzodiazepines were protective against tachycardia, diaphoresis, fatigue, and insomnia, while SSRIs were associated with abnormal ejaculation and benzodiazepines were associated with libido reduction 5

Diagnosis and Treatment in Emergency Medicine

• Panic disorder is a recognized psychiatric illness that can be treated in emergency medicine, with proper recognition and categorization being crucial for initiating appropriate treatment 7
• A review of treatment options for panic disorder highlights the need for further research on the pharmacological treatment of panic disorder, including head-to-head comparisons of SSRIs and benzodiazepines 3, 4