What are the diagnostic criteria and treatment options for panic disorder?

From the Guidelines

Panic disorder is diagnosed when a person experiences recurrent, unexpected panic attacks followed by at least one month of persistent worry about having more attacks, concern about their implications, or significant behavioral changes related to the attacks, as defined by the DSM-5 criteria 1. According to diagnostic criteria, a panic attack involves an abrupt surge of intense fear with at least four symptoms such as heart palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, dizziness, chills or heat sensations, numbness, feelings of unreality, fear of losing control, or fear of dying.

Diagnostic Criteria

The diagnostic criteria for panic disorder, as outlined in the DSM-5, include:

• Recurrent unexpected panic attacks
• At least one month of persistent worry about having more attacks, concern about their implications, or significant behavioral changes related to the attacks
• The panic attacks are not better explained by another mental disorder, such as social anxiety disorder or obsessive-compulsive disorder

Treatment Options

Treatment typically involves a combination of psychotherapy and medication.

• Cognitive-behavioral therapy (CBT) is the most effective psychotherapy approach, helping patients identify and change thought patterns that trigger panic symptoms 1. For medications,
• selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily), paroxetine (20-60 mg daily), or fluoxetine (20-80 mg daily) are first-line treatments, usually continued for at least 6-12 months after symptom improvement 1.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (75-225 mg daily) are also effective.
• Benzodiazepines such as clonazepam (0.5-2 mg daily) or alprazolam (0.5-4 mg daily in divided doses) can provide rapid relief but are generally used short-term due to dependency risks.

Lifestyle Modifications

Lifestyle modifications including regular exercise, stress management techniques, adequate sleep, and avoiding caffeine, alcohol, and stimulants can significantly complement formal treatments. These approaches work by addressing both the neurochemical imbalances and the psychological factors that contribute to panic disorder. In some cases, beta-blockers may be prescribed for symptom relief, combined with cognitive behavior therapy and/or a selective serotonin reuptake inhibitors and/or a benzodiazepine 1.

From the FDA Drug Label

Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, i.e., a discrete period of intense fear or discomfort in which 4 (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes.

The diagnostic criteria for panic disorder include:

• Recurrent unexpected panic attacks
• At least 4 of the 13 symptoms listed above
• Symptoms develop abruptly and reach a peak within 10 minutes
• 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

Treatment options for panic disorder include:

• Paroxetine (PO) 2
• Alprazolam (PO) 3 and 3

From the Research

Diagnostic Criteria for Panic Disorder

• According to the DSM-IV, panic disorder is defined as "The presence of recurrent panic attacks followed by at least one month of persistent concern about having another panic attack, worry about the possible implications or consequences of the panic attack, or a significant behavioral change related to the attacks" 4.
• A panic attack is defined as "a discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes" 4, including:
  • Palpitations, pounding heart or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, light-headed or faint
  • Derealization or depersonalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias
  • Chills or hot flashes

Treatment Options for Panic Disorder

• Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for panic disorder, as they are effective and well-tolerated 5.
• Cognitive behavioral therapy (CBT) is the psychologic treatment of first choice for panic disorder 5.
• Benzodiazepines may be used for short-term treatment or for treatment-resistant patients, but should be reserved for patients without a history of dependence and tolerance 5.
• Combination therapy, such as combining SSRIs with CBT or benzodiazepines, may be effective for some patients 6, 5.
• Other treatment options, such as tricyclic antidepressants and monoamine oxidase inhibitors, may be considered for patients who do not respond to first-line treatments, but may have more side effects and limitations 5.

Comparison of Treatment Options

• SSRIs and benzodiazepines are two commonly used treatment options for panic disorder, but they have different benefits and risks 7.
• SSRIs have a delayed onset of action, but are effective and well-tolerated in the long term 7.
• Benzodiazepines have a rapid onset of action, but can cause tolerance and dependence 7.
• Head-to-head comparisons of SSRIs and benzodiazepines are limited, and more research is needed to determine the best treatment approach for individual patients 7.